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Admission Date: [2117-9-11] Discharge Date: [2117-9-17] Date Birth: [2082-3-21] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[First Name3 (LF) 2195] Chief Complaint: nausea, vomiting Major Surgical Invasive Procedure: none History Present Illness: 35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy, nephropathy, HTN, gastroparesis, CKD retinopathy, recently hospitalized orthostatic hypotension [2-3] autonomic neuropathy [Date range (1) 25088]; DKA hospitalizations [6-12] [7-12], returning w/ 5d history worsening nausea, vomiting coffee-ground emesis, chills, dyspnea exertion. Last week fall hit right face. also 1 day diarrhea, resolved early last week. Found DKA AG 30 bicarb 11. . ED inital vitals 09:00 0 98.2 113 181/99 22 100% RA. K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) 3rd L NS. Insulin srip 5 units/hr. home 22 levemir 12 difficult control sugars. BPs high. Given 30 mtroprolol tartrate ED. started insulin drip 5 units/hr 3L NS boluses. Also aspirin 325mg PO Morphine 4mg IVx1 pain. CXr clear. EKG NAD. . Review systems: otherwise negative. Past Medical History: Type 1 diabetes mellitis w/ neuropathy, nephropathy, retinopathy - 2 episodes DKA [6-12] [7-12] HTN - 5 years gastroparesis - 1.5 years CKD - stage III, baseline Cr 2.4-2.5, proteinuria L1 vertebral fracture - [2117-7-17] Systolic ejection murmur Social History: Patient lives home [Location (un) ] 8 y/o daughter boyfriend. history EtOH, tobacco, illicit drug use. currently unemployed seeking disability. Family History: parents HTN T2DM. Grandfather MI 40s. Physical Exam: GEN: Awake, alert, oriented HEENT: PERRLA. MMM. JVD. neck supple. cervical LAD Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard best L upper sternal border. Pulm: CTABL crackles wheezes. Abd: BS+, soft, NT, rebound/guarding, HSM, [Doctor Last Name 515] sign Extremities: wwp, edema. radials, DPs, PTs 2+. Skin: rashes bruising. skin tenting. Neuro: CNs II-XII intact. Upper extremities: Power [5-6] bilaterally. Le: left power: 4.5/5 right: power [3-6]. Bilateral symmetric, reduced sensation distal LE ankles. Pertinent Results: Admission Labs: [2117-9-11] 09:22AM WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466* LIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5 GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9 CL-101 CO2-11* LACTATE-1.9 Discharge Labs: [2117-9-16] 07:10AM WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298 Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23 AnGap-14 Calcium-8.7 Phos-3.5 Mg-2.0 Radiology: CXR: evidence pneumonia pathological abnormalities. pleural effusions. pulmonary edema. Normal size cardiac silhouette. Microbiology: Urine culture negative, blood cultures growth date, stool C.difficile negative Brief Hospital Course: 35 yo F HTN & poorly controlled type DM, c/b neuropathy, gastroparesis, nephropathy ?????? CKD, retinopathy presents DKA hypertension SBP 200s. . # Diabetic ketoacidosis: Patient controls diabetes home Humalog SS long acting Levemir. Sugars home recently 250s. ED, glucose 466. UA +ve ketones ?????? corrected 200s, rose 300s. treated insulin drip transitioned subq tolerated POs. electrolytes repleted received aggressive volume resuscitation. [Last Name (un) ] saw gave sliding scale recommendations implemented. source DKA found, beleived [2-3] gastroparesis. Nausea managed ativan, compazine, promethazine. discharged home Insulin sliding scale instructions follow-up [Last Name (un) ]. # HTN: Hypertensive SBP 190s initially, attributed DKA, experienced past. improved blood pressures normalized re-started home Lopressor Midodrine regimen. # Coffee grounds emesis: Emesis started clear, prolonged wretching, started coffee-grounds vomiting. also occurred prior admissions DKA associated vomiting. hematocrit remained stable hematemesis self-resolved, work-up deferred outpatient setting. # Acute chronic kidney disease, Stage III: Patient's Cr admission 2.7, trending 2.1-2.3 following fluids, consistent known CKD secondary diabetic nephropathy. Medications Admission: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous every AM. 3. Levemir 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous bedtime. 4. Humalog 100 unit/mL Solution Sig: sliding scale directed Subcutaneous four times day: Please use sliding scale directed MD [First Name8 (NamePattern2) 767] [Last Name (Titles) ]. 5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): take evening. 6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) needed nausea. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take 1 capsule daily (30 mg) first 2 weeks treatment. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight (8) hours needed pain. 10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4) hours: hold sleeping. Disp:270 Tablet(s) Refills:2 Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Daily 6 PM. 5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Levemir 100 unit/mL Solution Sig: directed [Last Name (un) ] units Subcutaneous directed. Discharge Disposition: Home Discharge Diagnosis: Diabetic keotacidosis Hematemesis (blood vomit) Hypertension Chronic renal insufficiency Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted hospital DKA, hypertension, blood vomit. initially treated ICU insulin drip, blood sugars improved. blood pressure medications adjusted better control blood pressure DKA, re-started home regimen discharge. blood vomit likely secondary mechanical trauma repeated wretching, follow-up primary care doctor discuss whether undergo evaluation upper endoscopy. Given complaints chronic cough heartburn, also discuss beginning trial proton pump inhibitor Nexium Prilosec see helps symptoms. insulin regimen adjusted [Last Name (un) ] team here. continue follow-up questions concerns regarding insulin management. Followup Instructions: Please call Dr.[Last Name (STitle) 805]' office schedule follow-up appointment within 7-10 days discharge. office number [Telephone/Fax (1) 85219]. also continue follow-up [Last Name (un) ] doctors needed.	[ "5849" ]
Admission Date: [2150-4-17] Discharge Date: [2150-4-21] Date Birth: [2090-5-19] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: coffee ground emesis Major Surgical Invasive Procedure: EGD Right IJ CVL History Present Illness: Mr. [Known lastname 52368] 59M w HepC cirrhosis c/b grade I/II esophageal varices portal gastropathy (last EGD [3-/2150]), p/w coffee-ground emesis melena x2 days. . Pt USOH 2-3 days PTA, began experiencing intermittent nausea. 2-3 episodes coffee-ground emesis 1 episode tarry black stool morning admission. reports lightheadedness new, denies frank hematemesis, BRBPR, abdominal pain, fever, chills, significant increases abdominal girth. denies drinking medication non-compliance. also reports taking naproxen back pain 2-3 times day recent past. . ED, vitals 97.4, 93/41, 69, 18, 100% RA. given 4L NS IV, protonix 40mg IV, started octreotide drip. guaiac positive brown stool rectal exam. seen liver fellow ED felt unlikely variceal bleed recommended work infection. NG tube attempted, however, patient unable tolerate ED. Abdominal ultrasound done showed patent portal vein, scant ascites enough tap. BP dropped 80/34, pt transferred MICU hemodynamic monitoring. . MICU, pt given 3 pRBC, Hct bumped 21.3 28. Started norepinephrine gtt hours, BP stabilized. transfer floor, remains hemodynamically stable. Feels good, denies tarry bloody BMs, emesis. Past Medical History: HCV Cirrhosis (tx interferon x2 response) Portal Gastropathy Grade II Esophageal varices HTN Social History: lives alone. drinking alcohol, usually one session per week. four five drinks per session. told completely abstain alcohol, effective today. smokes 20 cigarettes per day. Family History: NC Physical Exam: ADMISSION: VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC Gen: somnolent, oriented x 3, unable assess asterixis given somnolence HEENT: PERRLA, EOMI Neck: supple, JVP angle jaw (fluid bolus running wide open) CV: RRR s1 s2 appreciable murmur Lungs: CTAB Abd: distended, non tender, rebound guarding, bowel sounds positive Ext: 1+ pitting edema bilaterally Skin: warm, diaphoretic, rash lesions noted Pertinent Results: LABS ADMISSION: [2150-4-17] 01:30PM BLOOD WBC-17.9# RBC-2.78 Hgb-8.5* Hct-26.0* MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186 [2150-4-17] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2 Baso-0.9 [2150-4-17] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6* [2150-4-17] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131* K-5.7* Cl-104 HCO3-21* AnGap-12 [2150-4-17] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426* AlkPhos-157* TotBili-3.3* [2150-4-17] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9 . LABS DISCHARGE: [2150-4-21] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0* MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110* [2150-4-21] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6* [2150-4-21] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132* K-4.4 Cl-99 HCO3-25 AnGap-12 [2150-4-21] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111 TotBili-3.6* [2150-4-21] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7 . LABS: [2150-4-18] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01 [2150-4-17] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01 [2150-4-17] 01:30PM BLOOD Lipase-85* . URINE: [2150-4-17] 11:01PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2150-4-17] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [2150-4-17] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE Epi-<1 . MICROBIOLOGY: Blood, urine cultures - negative H.pylori serum antibody - negative . CARDIOLOGY: . TTE ([4-18]): Conclusions left atrium dilated. Left ventricular wall thicknesses cavity size normal. Left ventricular systolic function hyperdynamic (EF>75%). Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. moderate pulmonary artery systolic hypertension. pericardial effusion. IMPRESSION: Hyperdynamic LV systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. . EKG ([4-17]): Sinus rhythm Prolonged QT interval nonspecific clinical correlation suggested previous tracing available comparison Intervals Axes Rate PR QRS QT/QTc P QRS 70 160 96 462/479 70 55 52 . GI: EGD ([4-20]): 1. Varices lower third esophagus middle third esophagus. 2. Erythema erosion antrum pylorus compatible non-steroidal induced gastritis. 3. Bleeding pyloric ulcer pylorus compatible non-steroidal induced ulcer (injection, thermal therapy). 4. Normal mucosa duodenum. 5. Otherwise normal EGD third part duodenum . RADIOLOGY: . CXR ([4-17]): prominent bulge right heart border could due pericardial effusion, _____ cyst, enlarged right atrium. mediastinal vascular engorgement suggest cardiac tamponade. Pulmonary vasculature normal. lungs clear pleural effusion. Overall heart size normal. Right jugular line ends junction brachiocephalic veins. pneumothorax pleural effusion. . ABD U/S ([4-17]): IMPRESSION: 1. son[Name (NI) 493] evidence portal venous thrombosis. Portal vein flow hepatopetal wall-to-wall. 2. significant ascites. sliver perihepatic ascites. 3. Persistent coarsened echotexture liver consistent known history cirrhosis. 4. Splenomegaly Brief Hospital Course: Mr [Known lastname 52368] 59M w HCV cirrhosis w grade II esophageal varices admitted w coffee-ground emesis melena concerning UGIB, s/p MICU stay hypotension. . # UGIB: Pt bleeds hospital. EGD revealed erythema erosion antrum pylorus compatible non-steroidal induced gastritis. Pt remember taking increased doses naproxen backache. Started pantoprazole 40mg PO BID one week repeat endoscopy scheduled one week ([4-30]). Recommended take tylenol (max daily dose 2gm) pain instead NSAIDs. Blood pressure meds held first, given MICU admission hypotension, restarted discharge. . # HCV Cirrhosis: appears progressing liver failure, elevated INR 1.6, decreased albumin 2.6, tbili slightly elevated 3.6, chronic LE edema. Pt continued prophylactic medications. . # FULL CODE Medications Admission: FUROSEMIDE 20mg daily LISINOPRIL 10 mg daily SPIRONOLACTONE 100 mg daily Discharge Medications: 1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane PRN (as needed). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO day. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [6-15] hours needed: 6 tablets regular strength tylenol per day. 8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times day) 1 weeks. Disp:qs Refills:0 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice day 1 weeks: take 1 tablet daily. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times day) needed itching. Disp:qs Refills:0 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO day. Discharge Disposition: Home Discharge Diagnosis: Peptic ulcer GI bleed Discharge Condition: asymptomatic Discharge Instructions: admitted bleeding ulcer stomach. ulcer least partially caused naproxen. stop taking naproxen take tylenol pain. take NSAIDS pain including ibuprofen, naproxen, aleve, motrin, aspirin, toradol, advil. okay take tylenol take 4 extra strength tylenol day (2gram daily maximum). . following medication changes made: take naproxen Take pantoprazole 40 mg twice daily one week. take 40 mg daily. . scheduled get repeat endoscopy next week. Prior procedure anything drink eat midnight. . Please return ER chest pain, lightheadeness, fever, chills, bloody black stools concerning symptoms. Followup Instructions: Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2150-4-30] 1:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7290], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2150-4-30] 1:30 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2150-5-7] 11:00 Completed by:[2150-4-24]	[ "2851", "4019" ]
Admission Date: [2108-4-6] Discharge Date: [2081-4-7] Date Birth: [2059-5-7] Sex: F Service: MED CHIEF COMPLAINT: Dyspnea. HISTORY PRESENT ILLNESS: 48 year old African American female history multiple myelomas admitted respiratory distress. patient recently discharged one week ago outside hospital ([Hospital3 7900]) respiratory distress. Back [Hospital3 7362], given nebulizer, antibiotics steroids. also elevated INR given medication lower INR although evidence bleeding. Last night, reports increased difficulty breathing. also cough. denies fever chills. patient admitted decreased p.o. intake recently sedimentary. denies swelling legs. patient noted wheezing took Albuterol inhaler without effect. Prednisone taper reports coughing thick sputum. went primary care provider today could say sentence sent Emergency Department. Emergency Department, tachypneic wheezing heart 120 blood pressure 127/82. received Solu-Medrol continued nebulizer treatment. improved, seemed tiring. ABG done showed pH 7.41; PCO2, 40; PO2, 92. speak full sentences still making wheezing. requiring continued nebulizer treatment denies chest pain, nausea, vomiting, diarrhea abdominal pain. feels weak general. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed [2107-12-9], increase protein bone marrow biopsy. receive Decadron 40 mg q every week. 2. Pulmonary embolism, [2108-1-2]. 3. Asthma. PFTs ..................... 4. History steroid psychosis. 5. Pneumonia requiring intubation [2107-12-9]. MEDICATIONS UPON ADMISSION: 1. Coumadin 2.5 mg p.o. q d. 2. Serevent two puffs q.i.d. 3. Albuterol inhaler one two puffs q 6 hours prn. 4. Dexamethasone 10 mg p.o. q d. ALLERGIES: known drug allergies. SOCIAL HISTORY: Socially, lives children works home home health aid. twenty years two pack day smoking history quit [2107-12-9]. drinks occasional alcohol. FAMILY HISTORY: Family history shows father died myocardial infarction. Sister ovarian cancer. PHYSICAL EXAMINATION UPON ADMISSION: Temperature, 96.6; heart rate, 122; blood pressure, 127/82; respiratory rate, 24; O2 saturation, 99%. Head, eyes, ears, nose throat, pupils equal, round, reactive light accommodation extraocular movements intact. accessory muscles used. Neck supple without lymphadenopathy. Pulmonary, diffuse wheezing bibasilar crackles left greater right. Cardiac, regular rate rhythm normal S1 S2. murmurs thrills noted. Abdomen soft, nontender, nondistended normal active bowel sounds. Extremities, edema, cyanosis clubbing noted. Neurologically, patient somnolent oriented x 3. focal defects noted. LABORATORIES UPON ADMISSION: White count, 9.6; neutrophils, 66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%. Sodium, 131; potassium, 4.4; chloride, 92; bicarbonate, 24. BUN, 14; creatinine, 0.8. Glucose, 131. INR, 1.3. PTT, 29.1. ABG, 7.41; PCO2, 40; PO2, 92. HOSPITAL COURSE: 1. Pulmonary - Dyspnea secondary chronic obstructive pulmonary disease/emphysema hospital course. Briefly, patient received BIPAP, ...................., intravenous Solu-Medrol, nebulizer treatment inhaler treatment Intensive Care Unit. able weaned oxygen back room air, sating 93 94 percent. Though chest x-rays show hyperinflation signs infection, given five days worth Zithromax. echocardiogram rule cardiac wheezes showed ejection fraction greater 55%, mild right ventricular dilation mild pulmonary arterial pressure. Pulmonary function tests performed showing obstructive pattern FEC 2.56 93% predicted FEV1 0.9 43% predicted FEV1 FEC ratio 46%. patient transferred Medical Floor, CT performed showed evidence pulmonary embolism show signs emphysema. Sputum cultures sent showed growth organism. Alpha antitrypsin sent still pending. 2. Pulmonary Embolism - patient continued Coumadin INR 2 3. Since subtherapeutic, started Lovenox became therapeutic Coumadin. 3. Psychiatry - Anxiety. patient quite anxious hospital course. Psychiatry called consult recommended Risperidone 0.25 mg q hs. patient well medication. 4. Oncology - Multiple myeloma. protein electrophoresis done showing monoclonal IGG capa gammaglobulinopathy (60% total protein [2108-1-8], 66% total protein [2108-4-9], despite q weekly Dexamethasone treatment. Bone marrow biopsy done revealing 70 80 percent plasma cells. Given findings, patient transferred [Hospital Ward Name 516] start chemotherapy Vincristine, ................... Decadron preparation bone marrow transplant done. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 8285] Dictated By:[First Name3 (LF) 30667] MEDQUIST36 D: [2108-4-17] 15:47 T: [2108-4-17] 15:46 JOB#: [Job Number 30668]	[ "486" ]
Admission Date: [2145-3-31] Discharge Date: [2145-4-7] Date Birth: [2071-6-4] Sex: F Service: SURGERY Allergies: Penicillins / Dilantin Attending:[First Name3 (LF) 301] Chief Complaint: Severe abdominal back pain Unable take oral intake. flatus bowel movement. Abdominal distention. Major Surgical Invasive Procedure: Exploratory Laparotomy Lysis adhesions Small Bowel Resection Jejunosotomy History Present Illness: Ms [Known lastname ] 73 year old female history multiple abdominal surgeries, pancreatitis previous SBO. presented Emergency Department [2145-3-30] complaints [11-10] abdominal pain, radiating back began morning. complains distention, inability bowel movement, inability take oral intake, fever, chills diarrhea. Past Medical History: Chronic Pancreatitis Migraines Surgical history: Pancreatic diversion, cholecystectomy, appendectomy, small bowel obstruction. Social History: Married, lives husband retired pediatric infectious disease doctor. Family History: Father: deceased, leukemia Brother: colon cancer Physical Exam: T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% RA Constitutional: pain Head/Eyes: mucous membranes dry ENT/Neck: neck supple Chest/Respiratory: Clear auscultation Bilaterally GI/Abdominal: Tender light palpation. Multiple well healed scars + guarding, hypoactive bowel sounds GU: costovertebral angle tenderness Musculoskeletal: WNL Skin: Dry Neuro: alert & oriented Pertinent Results: [2145-3-30] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-25 AnGap-15 [2145-3-31] 10:26AM BLOOD WBC-12.3# RBC-4.01 Hgb-12.3 Hct-37.1 MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259 [2145-3-30] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169* TotBili-0.3 [2145-4-2] 06:15AM BLOOD Amylase-107* [2145-3-31] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6 [2145-3-31] 12:44AM BLOOD Lactate-3.1* [2145-4-2] 02:10PM BLOOD Lactate-1.9 [2145-3-30] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . ABDOMEN (SUPINE & ERECT) IMPRESSION: Nonspecific bowel gas pattern without evidence obstruction. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. High grade small-bowel obstruction. Unusual configuration loop small bowel mid abdomen concerning closed loop obstruction. moderate amount free fluid within abdomen. 2. Ill-defined opacity right middle lobe representing infection BAC evaluated PET CT. 3. Thickening first portion duodenum, uncertain clinical significance. . CHEST (PORTABLE AP) [2145-4-2] 1:51 PM IMPRESSION: Right lower lobe airspace opacity, could represent pneumonia appropriate clinical setting. Small bilateral pleural effusions. Followup assure resolution recommended. . CT Chest [2145-4-2] IMPRESSION: 1. New right lower lobe pneumonia. Small bilateral pleural effusion left basilar atelectasis. 2. Ill-defined opacity right middle lobe representing either infection BAC evaluated acute issues resolve. 3. evidence pulmonary embolus aortic dissection. 4. Small mediastinal axillary lymph nodes, meet CT criteria pathologically enlargement. CXR [2145-4-6] IMPRESSION: 1. Improving airspace consolidation right lower lung field consistent resolving pneumonia. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms [Known lastname ] admitted emergency room [2145-3-31] taken operating room. underwent uncomplicated exploratory laparatomy small bowel resection, jejunosotomy lysis adhesions, see op report details. stabilized PACU, transferred SICU POD#1. extubated, pain well controlled morphine PCA, remained NPO NGT foley catheter. initiated Cefazolin/Flagyl x 24 hours. POD#2 developed confusion decreased oxygen saturation, requiring 3L nasal cannula. Narcotics stopped, CXR CT chest obtained revealed right lower lobe pneumonia, see pertinent results details. Vanc/Levo/Flagyl initiated well ID medicine consult. transferred SICU. POD#[4-4] remained SICU, mental status respiratory status improved. POD#4 NGT removed transferred [Hospital Ward Name 121] 9, weaned room air. pain well controlled tylenol small doses oxycodone. POD#5 reported flatus followed multiple loose stools. Stool C diff negative. started sips, tolerated easily. POD#6 tolerated clear liquids longer wanted take antibiotics due frequent stools. CXR repeated showed resolving pneumonia. tolerated regular diet evening without difficulty. Infectious disease team recommended completion 7 days Levofloxacin. Clips removed POD#7, discharged home stable condition antibiotics, pain medication appropriate follow appointments. Medications Admission: Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) needed. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume home dose trileptal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 6 hours) needed. Disp:30 Tablet(s) Refills:0 2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. 5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO day. Disp:7 Tablet(s) Refills:0 Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume home dose trileptal Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Internal hernia necrotic jejunum Pneumonia Discharge Condition: good Discharge Instructions: Please call surgeon develop chest pain, shortness breath, fever greater 101.5, foul smelling colorful drainage incisions, redness swelling, severe abdominal pain distention, persistent nausea vomiting, inability eat drink, symptoms concerning you. tub baths swimming. may shower. clear drainage incisions, cover dry dressing. Leave white strips incisions place, allow fall own. Activity: heavy lifting items [11-15] pounds follow appointment doctor. Medications: Resume home medications. problem constipation, take stool softener, Colace 100 mg twice daily needed. given pain medication may make drowsy. driving taking pain medicine. Followup Instructions: Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2145-4-20] 2:00 appointment see Dr. [Last Name (STitle) ] Friday, [2145-4-23] 3:30. Phone #: [Telephone/Fax (1) 2723]. Please see primary care physician regarding follow CT scan within 1 month. CT results Discharge summary faxed her. Completed by:[2145-4-7]	[ "486", "4019" ]
Admission Date: [2162-5-16] Discharge Date: [2162-5-21] Date Birth: [2101-7-30] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Angina Major Surgical Invasive Procedure: [2162-5-17]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior Descending Artery, Obtuse marginal [2162-5-19]: Right Atrial lead placement History Present Illness: 60yo man known coronary disease (AMI [2143] [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LCx [2155]). well last week developed angina initially exertion progressed rest angina. episode releived SL NTG, episode lasting 5 minutes. presented cardiologist treatment. admitted MWMC, cardiac catheterization revealed 3 vessel disease. transferred [Hospital1 18] coronary bypass grafting. Cardiac Catheterization: Date: [2162-5-11] Place: MWMC -LAD- chronic total occlusion proximally(distal filling via collaterals) -RCA- chronic total occlusion non-dominant RCA 90% -LCx- new complex 90% stenosis prox LCx involving bifurcation LCx proper large OM2. Old stent LCx widely patent -mod LV systolic dysfx, anterior, apical, infero-apical AK reduced EF 30% LVEDP 36mmHg valvular dz Past Medical History: CAD-(AMI [2143-7-3], [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LCx [6-/2155]) Cardiomyopathy- EF 35-45% depending study Ventricular tachycardia s/p AICD [8-/2155] Atrial flutter s/p ablation [8-/2155] Hypertension Dyslipidemia Insulin dependent diabetes Mellitus Obesity Conduction disease-LAFB Peripheral vascular disease s/p Right fem-[Doctor Last Name ] bypas [3-/2161] Left leg claudication Right thigh tumor s/p radiation excision [2141]'s Social History: Race: caucasian Last Dental Exam: Lives with: wife Occupation: [Name2 (NI) 56028] owns company Tobacco: 2ppd x20 yrs quit [2143] ETOH: occaisional Family History: Father died 50yo cirrhosis, mother died 42yo MI Physical Exam: Pulse: 58 Resp: 16 O2 sat: 97%-RA B/P Right: 124/76 Left: Height: 5'[62]" Weight: 259 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x]. Well healed right vein harvest site. Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: [2162-5-17]: Prebypass left atrium dilated. spontaneous echo contrast seen body left atrium left atrial appendage. spontaneous echo contrast seen body right atrium. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity severely dilated. moderate regional left ventricular systolic dysfunction hypokinesis apex septum. Overall left ventricular systolic function mildly depressed (LVEF=30-35%). estimated cardiac index depressed (<2.0L/min/m2). Focal abnormalities seen mid apical anteroseptal wall, apical anterior wall, mid apical inferoseptal wall, apical inferior wall. thrombus seen LV apex. Right ventricular chamber size free wall motion normal. descending thoracic aorta mildly dilated. aortic valve leaflets (3) mildly thickened focal calcification non-coronary cusp moves poorly. minimally increased gradient consistent minimal aortic valve stenosis. aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild moderate ([1-3]+) mitral regurgitation seen. mitral valve prolapse flail segments. pericardial effusion. Postbypass patient A-paced phenylephrine infusion. Biventricular systolic function unchanged. Mitral regurgitation remains mild-to-moderate. thoracic aorta intact post decannulation. [2162-5-20] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7* MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114* [2162-5-20] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [2162-5-16] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73 TotBili-0.3 Brief Hospital Course: patient admitted hospital brought operating room [2162-5-17] patient underwent Coronary artery bypass graft x 4. See operative note details. Overall patient tolerated procedure well post-operatively transferred CVICU stable condition recovery invasive monitoring. POD 1 found patient extubated, alert oriented breathing comfortably. Electrophysiology team consulted due non capturing atrial lead permanent pacemaker initially interrogated epicardial wires removed. Ventricular lead ICD functioning appropriately. right atrial lead revised [5-19] without complication. follow device clinic [Hospital1 ] 2 weeks - operative note given patient bring follow appointment. patient neurologically intact hemodynamically stable inotropic vasopressor support. Beta blocker initiated patient gently diuresed toward preoperative weight. Lisinopril restarted better blood pressure. patient transferred telemetry floor recovery. Chest tubes discontinued without complication post operative day 3. patient evaluated physical therapy service assistance strength mobility. time discharge POD 4 patient ambulating freely, sternal pacer pocket wound healing pain controlled oral analgesics. continue 1 week antibiotics per EP s/p atrial lead placement. patient discharged home VNA services good condition appropriate follow instructions. follow appointments arranged. Medications Admission: Lisinopril 20' Atenolol 100' Vytorin [10/2131] QHS Fenofibrate 200' ASA 325' NTG-sl/PRN Insulin-NPH 22u QAM/24u QPM- followed [Last Name (un) ] Insulin- Humalog SS MVI Calcium 600' Plavix - last dose:[2162-5-12] Allergies: NKDA Discharge Medications: 1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:0 2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:1 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:100 Tablet(s) Refills:0 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. Disp:65 Tablet(s) Refills:0 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) 7 days. Disp:28 Capsule(s) Refills:0 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 7 days. Disp:7 Tablet(s) Refills:0 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO day 7 days. Disp:7 Tablet, ER Particles/Crystals(s) Refills:0 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed pain. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice day: Take 22 units 24 units PM. Disp:QS 1 month Refills:0 16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Coronary Artery Disease CAD-(AMI [2143-7-3], [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LCx [6-/2155]),Cardiomyopathy- EF 35-45% Ventricular tachycardia s/p AICD [8-/2155], Atrial flutter s/p ablation [8-/2155], Hypertension, Dyslipidemia,Insulin dependent diabetes Mellitus, Obesity, Conduction disease-LAFB, Peripheral vascular disease s/p Right fem-[Doctor Last Name ] bypas [3-/2161], Left leg claudication, Right thigh tumor s/p radiation excision [2141]'s Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed Percocet Incisions: Sternal - healing well, erythema drainage Leg Left - healing well, erythema drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments Surgeon: Dr [Last Name (STitle) ] [6-10] 1:45pm [Telephone/Fax (1) 170] Cardiologist: Dr. [Last Name (STitle) 1295] [6-14] 3:30pm EP [Hospital 19721] Clinic [Hospital1 ] [1-3] weeks: Call appointment - [Telephone/Fax (1) 6256] Wound check appointment [Hospital ] Medical office building [Telephone/Fax (1) 170] Date/Time:[2162-5-26] 12:00 Please call schedule appointments Primary Care Dr. [Last Name (STitle) 27187] [4-6] weeks [Telephone/Fax (1) 3658] Follow [Hospital ] [Hospital 982] Clinic arranged patient Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Completed by:[2162-5-24]	[ "2859", "4019", "2720" ]
Admission Date: [2177-8-29] Discharge Date: [2177-9-12] Date Birth: [2156-2-27] Sex: Service: SURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: Helmeted motocyclist hit tree Major Surgical Invasive Procedure: [2177-8-29] 1. Irrigation debridement inclusive bone, right open femur fracture. 2. Retrograde intramedullary nailing Synthes 11 x 360 nail. 3. Open reduction internal fixation patella fracture K-wires figure-of-8 tension band construct. [2177-9-4] Tracheostomy IVC filter [2177-9-12] PICC right bascilic vein History Present Illness: 21 y.o. male helmeted moped rider struck tree reported GCS 6 scene. Patient transported OSH noted right sided open femur fracture. received antibiotics intubated prior transfer. Patient transported radiographic studies performed showed right femur fracture, SAH, grade II liver lac, pulmonary contusions, small PTX. Patient reportedly received 1 unit pRBCs ED placed traction splint RLE. Past Medical History: None Social History: tobacco none ETOH none Family History: Non-contributory. Physical Exam: 96.9 130 150/97 20 100% intubated sedated HEENT - L eye abrasions, pupils nonreactive bilaterally CTA b/l rapid HR, regular rhythm SNDNT pelvic fracture + palpable distal pulses Pertinent Results: [2177-8-29] 04:35AM BLOOD WBC-17.7* RBC-4.76 Hgb-15.2 Hct-45.5 MCV-96 MCH-32.0 MCHC-33.5 RDW-13.2 Plt Ct-314 [2177-8-30] 12:50AM BLOOD WBC-7.6 RBC-2.73* Hgb-9.0* Hct-25.0* MCV-92 MCH-32.8* MCHC-35.9* RDW-13.5 Plt Ct-188 [2177-8-31] 01:49AM BLOOD WBC-9.4 RBC-2.42* Hgb-7.8* Hct-21.7* MCV-89 MCH-32.1* MCHC-35.9* RDW-14.5 Plt Ct-148* [2177-9-1] 03:13AM BLOOD WBC-9.2 RBC-2.87* Hgb-9.0* Hct-25.6* MCV-90 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-128* [2177-9-2] 01:40AM BLOOD WBC-7.7 RBC-2.78* Hgb-8.8* Hct-24.6* MCV-88 MCH-31.5 MCHC-35.7* RDW-15.4 Plt Ct-164 [2177-9-3] 12:53AM BLOOD WBC-8.9 RBC-2.94* Hgb-9.3* Hct-26.2* MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-220 [2177-9-4] 01:08AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-27.3* MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-313 [2177-9-5] 02:32AM BLOOD WBC-8.4 RBC-2.91* Hgb-9.0* Hct-26.9* MCV-92 MCH-30.9 MCHC-33.5 RDW-15.6* Plt Ct-412 [2177-9-6] 01:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.0* Hct-26.5* MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt Ct-418 [2177-9-7] 02:12AM BLOOD WBC-14.4* RBC-3.00* Hgb-9.3* Hct-27.6* MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt Ct-556* [2177-9-8] 01:59AM BLOOD WBC-14.7* RBC-3.25* Hgb-10.0* Hct-29.7* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748* [8-29] CT head - Multiple foci parenchymal hemorrhage well small amount likely subarachnoid hemorrhage. location foci [Doctor Last Name 352]-white matter interface concerning diffuse axonal injury CT Cspine - fracture traumatic malalignment cervical spine CT torso - Extensive pulmonary contusions, worse right left. Hepatic lacerations small amount abdominal pelvic free fluid intermittent density. Bilateral rib fractures. Right femur/knee xrays - mid shaft femoral fracture mild varus angulation distal fragment relative proximal. also medial subluxation ~ 1 cortical width. [9-2] MRI cspine - Edema interspinous ligaments C3-C4 C7-T1, without evidence distraction. lobal central canal narrowing due congenital short pedicles. slightly exacerbated disc bulge C3-4. cord signal abnormality. Moderate right C4-5 neural foramen narrowing due uncovertebral osteophytes. [9-3] Bilateral LE LENIs - deep venous thrombosis involving right left lower extremity. LUE LENI - deep venous thrombosis left upper extremity. [9-7] CT Abdomen/Pelvis - Right pleural effusion associated compressive atelectasis. Considerable improvement appearance right lobe liver laceration. Small amount free fluid pelvis. Fractures left first right fourth fifth ribs. Fracture right transverse process T1. Brief Hospital Course: patient admitted trauma ICU. [8-29] - Patient admittd ICU. taken operation room ortho ORIF right femur (see operative report full details). Neurosurgery consulted ICP placed. started dilantin q1 hour neurochecks. [Date range (1) 58392] - patient transfused 4u PRBC decreasing Hct. right femur hematoma expanding limb soft fear compartment symdrome. Hct stabilized. Head CT stable. [9-1] - ICP discontinued neurosurgery signed off. Head CT stable. [9-2] - MR head c-spine performed. [9-3] - Bilateral LE LUE LENIs performed demonstrated DVT. [9-4] - patient went acute care service tracheostomy IVC filter placement. [9-6] - Patient dc'ed dophoff tube twice. [9-7] - CT A/P done persistent fevers rising white count. source fevers identified. Patient put trach collar. [9-8]: Awake, off-versed, following commands. Passed S&S regular diet Passy [Last Name (un) 87596] Valve. BAL cultures grew MRSA, kept Vanc now. Patient ready transferred floor, waiting bed. ` Following transfer Surgical floor continued make slow progress. trach tube plugged PMV tolerated well. confirming aspiration video swallow tolerating regular diet thin liquids. Physical Therapy Occupational Therapy services followed daily basis increase mobility increase cognitive abilities. memory decreased occasionally confusion improving day. PICC line placed [2177-9-12] IV antibiotics require Vancomycin thru [2177-9-16] MRSA pneumonia. minimal secretions undergoing nebulizer treatments. Potentially IVC filter removed Dr. [Last Name (STitle) ] evaluate weeks therefore need return [Hospital 2536] Clinic. also follow Neuro cognitive clinic Dr. [First Name (STitle) ] following discharge rehab. lonfg hospitalization transferred rehab [2177-9-12] therapy goal return home soon. Medications Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed temp > 101.5. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) needed constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times day). 4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times day) needed abrasions. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg Intravenous every eight (8) hours: thru [2177-9-16]. 10. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg PO Q2H (every 2 hours) needed pain. 11. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN pain Please use breakthrough PO/NG MSIR. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: S/P scooter v tree 1. Left eye abrasion 2. Rib fractures right [5-5], left 1 3. Bilat pulmonary contusions 4. Grade 2 liverlaceration 5. Open right femur fracture 6. Right thigh laceration 7. Right patellar fracture 8. Right metatarsal neck fracture [3-7] 9. Small SAH 10.Right TP fracture T1 11.[Doctor First Name ] 12.Acute blood loss anemia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: * admitted hospital multiple injuries following accident including head trauma, rib fractures, knee fracture liver laceration. * made alot progress need rehabilitation return home. * breathing well trach tube plugged hopefully removed improve. * Continue work physical therapy increase mobility. Followup Instructions: Please follow [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP orthopaedics 1 month, please call [Telephone/Fax (1) 1228] schedule appointment. Call [Hospital 2536] Clinic [Telephone/Fax (1) 600] follow appointment [3-5] weeks Call Vascular Surgery Clinic [Telephone/Fax (1) 1237] appointment 2 weeks Dr. [Last Name (STitle) ]. Call [Hospital 4695] Clinic [Telephone/Fax (1) 1669] follow appointment 6 weeks Dr. [First Name (STitle) ]. need Head CT prior appointment. secretary book you. Call Dr. [First Name (STitle) ] Neuro cognitive Clinic [Telephone/Fax (1) 1690] appointment discharge rehab Completed by:[2177-9-12]	[ "2851" ]
Admission Date: [2177-3-12] Discharge Date: [2177-3-22] Date Birth: [2109-6-26] Sex: Service: CARDIOTHORACIC Allergies: Shellfish Attending:[First Name3 (LF) 1505] Chief Complaint: exertional angina Major Surgical Invasive Procedure: [2177-3-14] Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary Artery Left Anterior Descending Artery, Saphenous Vein Graft Obtuse Marginal Artery, Saphenous Vein Graft Posterior Descending Artery History Present Illness: 67 year old man known coronary artery disease-s/p stents x 6(2004x5 [11-21]) developed exertional angina walking [3-9]. Angina resolved w/ rest minutes. Angina recurred [3-11], patient brought [Hospital ] Med Ctr enzymes negative. cardiac catheterization showed: tapering distal LM,70% osteal LAD,90% mid RCA. LVEF 60% LVgram. transferred [Hospital1 18] surgical management coronary artery disease. time transfer pain free. Past Medical History: Coronary artery disease(PCI/stents x6), Hypertension, HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[3-20] PSH:Left knee arthroscopy, Left chest Portacath Social History: Works administrator [University/College 33918]. Married, 2 children. Tob: Former smoker, quit 30 yrs ago. ETOH: Drinks beers cocktails per night. drugs Family History: Brother: MI 60, uncle: MI 50 Mother: htn Physical Exam: Pulse: Resp: O2 sat: B/P Right:130/72 Left: 128/72 Height: 70" Weight:175# General:WDWN, NAD Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x]glasses Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: Admission Labs: [2177-3-12] 04:05PM PT-11.7 PTT-23.8 INR(PT)-1.0 [2177-3-12] 04:05PM PLT COUNT-199 [2177-3-12] 04:05PM NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6* BASOS-0.5 [2177-3-12] 04:05PM WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97# MCH-35.6* MCHC-36.6* RDW-13.5 [2177-3-12] 04:05PM %HbA1c-5.2 eAG-103 [2177-3-12] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7 [2177-3-12] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK PHOS-100 TOT BILI-2.0* [2177-3-12] 04:05PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [2177-3-12] 04:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2177-3-12] 04:33PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 Discharge Labs: Radiology Report CHEST (PORTABLE AP) Study Date [2177-3-17] 7:29 Final Report: Comparison study [3-15], monitoring support devices removed except left subclavian catheter right IJ sheath. chest tube removed, evidence pneumothorax. Residual opacification left base consistent atelectasis effusion. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging interatrial septum raises suspicion atrial septal defect, could confirmed basis study. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Borderline normal RV systolic function. AORTIC VALVE: Three aortic valve leaflets. AS. Trace AR. MITRAL VALVE: MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve well seen. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. TEE related complications. patient appears sinus rhythm. Results personally reviewed MD caring patient. Conclusions Focused Intraoperative TEE chest exploration post-operative bleeding. Color-flow imaging interatrial septum raises suspicion atrial septal defect, could confirmed basis study. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). Borderline normal RV free wall function. three aortic valve leaflets. aortic valve stenosis. Trace aortic regurgitation seen. Mild (1+) mitral regurgitation seen. small pericardial effusion. Dr. [Last Name (STitle) ] notified person results. Brief Hospital Course: Mr [Known lastname 732] transferred fro [Hospital ] Med Ctr surgical management coronary artery disease. usual pre-operative workup brought operating room coronary artery bypass grafting [2177-3-14]. Please see operative report details. summmary had: Coronary Artery Bypass Grafting x3 Lwft Internal Mammary Artery Left Anterior Descending Artery, Saphenous Vein Graft Obtuse Marginal Artery, Saphenous Vein Graft Posterior Descending Artery. cardiopulmonary bypass time 51 minutes crossclamp time 39 minutes. tolerated operation well post-operatively transferred cardiac surgery ICU stable conditio. remained hemodynamically stable immediate post-op period. woke anesthesia neurologically intact extubated operative day. POD1 continued significant drainage chest tubes brought back operating room mediastinal exploration-no source bleeding found. tolerated procedure well returned cardiac surgery ICU stable condition. recovered anesthesia extubated shortly surgery completed. remained hemodynamically stable throughout period. tubes lines drains removed per cardiac surgery protocol. POD 3 transferred ICU stepdown floor continued post-op care recovery. Physical therapy worked patient advance activities daily living improve strength endurance. POD # 4, Pt develope drainage sternal incision. started IV Vancomycin. Betadine cleanse TID started. POD # [4-19], pts wound improved. discharged PO keflex x 10 days. wound DC without drainage. POD 10 discharged home visiting nurses. follow Dr [Last Name (STitle) ] 3 weeks, sternal check [3-26] [Hospital Ward Name ] 6. follow cardiologist, appt made, also instructed follow PCP. Medications Admission: Lisinopril 20mg daily, Lipitor 80mg daily, Plavix 75 mg [Last Name (LF) ], [First Name3 (LF) ] 325mg daily, Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. [Last Name (un) 1724] Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg [Hospital1 ],Plavix 75mg daily,NTG prn,Lipitor 80mg daily 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times day). Disp:180 Tablet(s) Refills:2 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 7 days. Disp:14 Tablet(s) Refills:0 8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice day 7 days. Disp:14 Tablet Extended Release(s) Refills:0 9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times day 10 days. Disp:40 Capsule(s) Refills:0 Discharge Disposition: Home Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Bypass Grafting x3 PCI/stents(6) PMH: Hypertension, HYPERCHOLESTEROLEMIA, CA- left vocal cord(RT/chemo)[3-20] PSH:lt knee arthroscopy, LT chest Portacath Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments Surgeon: Dr [First Name (STitle) ] [Name (STitle) ] [2177-4-10] 9AM [Hospital1 ] Cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5874] [2177-4-16] 3PM Please call schedule appointments Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) 488] J. [Telephone/Fax (1) 8036] [4-15] weeks wound check scheduled [5-26] 1000 hrs, please come [Hospital Ward Name ] 6 scheduled time. Thw midlevelers look wound see stable. Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Labs: PT/INR Coumadin ?????? indication Goal INR First draw Results phone fax Completed by:[2177-3-22]	[ "4019", "2720" ]
Admission Date: [2176-8-29] Discharge Date: [2176-9-6] Date Birth: [2121-2-13] Sex: Service: MEDICINE Allergies: Penicillins / Keflex Attending:[First Name3 (LF) 1928] Chief Complaint: Upper extremity weakness Major Surgical Invasive Procedure: C5-C6 anterior cervical decompression fusion, C1 tumor removal History Present Illness: 55-year-old man diabetes mellitus type 2, hypertension, severe peripheral [First Name3 (LF) 1106] disease s/p R SFA stent angioplasty L SFA stent placement, congenital pulmonic valve stenosis, CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p ablation warfarin, stage 3 diabetic nephropathy, intradural tumor compressing spinal cord C1/C2, admitted [2176-8-29] neurosurgery anterior cervical decompression C5/6 fusion ([8-29]) extradural tumor removal C1 intradural tumor ([8-30]). patient post-operatively managed ICU dexamethasone taper. developed small subdural hematoma ([8-30]) new neurologic symptom. Aspirin heparin SC restarted. Clopidogrel, L SFA stent, scheduled restarted POD#5, [2176-9-4], warfarin, atrial fibrillation, restarted [2176-9-9]. Patient extubated [9-1], coming furosemide drip dCHF. [Month/Day (4) ] following patient mottled right foot recent [Month/Day (4) 1106] procedures. Patient's medical issues diabetes, HTN, CKD (Cr 1.1), atrial fibrillation (HRs 70s-80s), CAD s/p stent "chronic hyponatremia" (Na 138) stable. Transfer requested ongoing management diastolic CHF. evaluation SICU transfer, patient sleeping arousable, complaining old back pain constipation. Vital signs stable O2 saturation 98% 3L. Past Medical History: (1) Type 2 diabetes mellitus, requiring insulin, complications years poor glycemic control: -hypertension -severe peripheral [Month/Day (4) 1106] disease -peripheral neuropathy -pressure, venous stasis, neuropathic ulcers right left lower extremities -stage 3 diabetic nephropathy -renal insufficiency (baseline creatinine 1.5 1.7) (2) Atrial fibrillation status post ablation [2169] [2174], coumadin (3) Congenital pulmonic valve stenosis status post two childhood surgeries -history RV failure -history peripheral edema anasarca (4) Chronic hyponatremia (5) Chronic low back pain status post car accident (6) Spinal cord meningioma compressing spinal cord C1/C2 (7) COPD (8) Coronary artery disease status post stenting [2169] (bare metal stent Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] ([Telephone/Fax (1) 8725])) repeat stenting [Hospital1 18] [2174] (bare metal stent - see d/c summary [2175-2-7]) (9) MI [2161] Social History: patient married two adult sons live home. lives [Hospital1 1474], MA. wife works 60 hours week, left home day. bedbound several years. visiting nurse come week change dressings lower extremity ulcers. sons struggle alcoholism heroin abuse. younger son recently threatened suicide homicide (against patient's wife), source much stress home. used work "bouncer" construction, enjoyed riding motorcycle. patient says tries keep positive attitude condition. says feels depressed, says interested therapy medication depression. seen primary care physician [Last Name (NamePattern4) ] 2 years travel ambulance PCP's office touch patient wife weekly. -[Name2 (NI) ] 2 pack per year smoking history "several years" -He drinks alcohol occasionally, never problem alcoholism -He denies recreational IV drug use Family History: Heart disease unspecificed family members. Physical Exam: Physical exam admission: Gen: obese, deconditioned, pain movement extremities. Extrem: B LE edema Neuro: Mental status: Awake alert, cooperative exam. Language: Speech fluent good comprehension repetition. Naming intact. dysarthria paraphasic errors. Motor: Patient severe bilateral wasting muscles hand. UE's: FI's:[2-1] 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [1-4] PF/DF 0/5 LLE: IP3/5 PF/DF 0/5 Pertinent Results: [2176-8-29] 12:10PM GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14 [2176-8-29] 12:10PM estGFR-Using [2176-8-29] 12:10PM WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78* MCH-24.9* MCHC-31.9 RDW-13.6 [2176-8-29] 12:10PM PLT COUNT-206 IMAGING STUDIES: # C-spine Xray [8-29]: Single lateral view cervical spine obtained portably OR, labeled #1. C1 C4/5 disc space visualized. C5 vertebral body faintly seen -- bony structures lower obscured overlying soft tissues. However, surgical markers seen overlying anterior aspects C4-5 C5-6 disc spaces, anterior approach. Support tubing temperature probles noted. # C-spine CT [2176-8-29]: 1. New interval C5-C6 anterior fusion intervertebral disc spacer, immediate hardware complication. Post-surgical changes soft tissue subcutaneous emphysema mostly right submandibular region. 2. Mass C1 level associated cord compression consistent known meningioma better described recent MRI. 3. Soft tissue thickening right lung apex, fully characterized current CT. comparison CT neck [2176-8-9], increased size. CT chest recommended evaluate further, clinically warranted. # Head CT [2176-8-30]: 1. New interval left frontal subdural hyperdense extra-axial fluid collection new interval subdural subfalcine extra-axial hyperdense fluid collection, indicating subdural hemorrhage, likely post-surgical clinical correlation recommended. 2. Pneumocephalus distribution basilar cisterns, mostly left sylvian fissure, bifrontally falx, likely post-surgical, additionally posterior fossa near site occipital craniotomy. 3. Post-surgical changes left craniotomy occipital bone laminectomy C1 subcutaneous emphysema hyperdense products, likely post-surgical. 4. Soft tissue hyperdensity posterior parietal, occipital soft tissue region, could small post-surgical hematoma. . # C-spine MRI [2176-8-31]: Status post resection C1 extradural tumor, likely meningioma expectorated postoperative changes. large intraspinal hematoma seen. remains persistent narrowing spinal canal C1 level indentation posterior aspect spinal cord. Continued followup recommended. Mild spinal cord atrophy could secondary chronic myelomalacia. . # LE arterial Duplex [2176-9-3]: peak systolic velocity involving native right common femoral artery 104 cm/sec. Velocities within superficial femoral artery range 85 234 cm/sec within popliteal artery right, 25 cm/sec. left, peak systolic velocity within common femoral artery 132 cm/sec, SFA, velocities range 146-75 cm/sec within popliteal artery 85 cm/sec. IMPRESSION: Findings stated indicate widely patent common femoral, superficial femoral popliteal arteries bilaterally. . PATHOLOGY: # C1 tumor [2176-8-30]: Cervical medullary junction tumor: Meningioma, psammomatous subtype (WHO Grade I). tumor composed meningothelial cells numerous psammoma bodies collagen deposition typical features mitotic activity. Brief Hospital Course: 55-year-old man diabetes mellitus type 2, severe peripheral [Month/Day/Year 1106] disease, CAD, diastolic CHF, atrial fibrillation, presented planned anterior cervical decompression C5-6 removal C1 meningioma. # Cervical myelopathy meningioma: Patient underwent anterior cervical decompression C5/6 fusion [2176-8-29] removal C1 meningioma [2176-8-30]. patient post-operatively managed ICU dexamethasone taper. developed small subdural hematoma [2176-8-30] new neurologic symptom. Per neurosurgery recommendations, aspirin heparin SC restarted. Clopidogrel, recent left SFA stent, restarted POD#5, [2176-9-4], warfarin, atrial fibrillation, restarted [2176-9-9]. note, concern developed LE weakness procedure, re-evaluation neurosurgery team felt strength legs baseline change. continued work PT hospitalization. # Diastolic heart failure: patient experienced acute exacerbation diastolic heart failure likely secondary significant fluid administration surgery. placed furosemide gtt SICU, transitioned home dose lasix floor. discharge slightly admission weight 115kg O2 sats mid 90's room air. # Peripheral [Date Range ] disease. patient recently underwent bilateral SFA angioplasties Left SFA stenting. preparation neurosurgery, plavix held pre-procedure subsequently re-started [2176-9-4]. underwent bilateral arterial ultrasound [2176-9-3] demonstrated patent SFA femoral arteries. # Atrial fibrillation: patient atrial fibrillation hospitalization. Given need neurosurgery coumadin held. scheduled restarted 10 days post-procedure ([2176-9-9]). well rate controlled time discharge. # DM II. patient's insulin regimin adjusted 50 units insulin glargine nightly humalog insulin sliding scale achieved good control blood sugars (FSBS 100-180). # Pressure ulcers. patient 2x2cm right heel full thickness ulcer without odor drainage. right dorsum small 1x1cm partial thickness ulcer. Wound care nursing consult obtained. Pressure ulcer care performed repositioning, skin cleansing conditioner application, cover ABD kerlex. # Coping. pt expressed staff members mood poor coping well surgery. never expressed suicidal ideations. expressed extremely frustrated hospitalization inability walk function independently. Discussed possibility talking psychiatrists hospital, declined. felt feeling persisted would pursue psychiatric care. number psychiatric services provided discharge. # Chronic pain syndrome: patient continued home regimen dilaudid 4mg PO Q3H:prn # Chronic hyponatremia. patient history chronic hyponatremia although sodium remained 130-140 admission. Medications Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN needed constipation. 2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [Hospital1 ] (2 times day): Hold SBP<100. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day): Hold SBP<100 HR<60. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) needed insomnia. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed fever. 8. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily): Please apply leg wounds per wound care orders. thank you! . 9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q6H: PRN needed shortness breath wheezing. 11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) needed pain: Hold RR<12 sedation. 12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN needed itching. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO BID: PRN needed constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation: hold diarrhea. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed anxiety. 18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) needed dry mouth, sore throat. 19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times day): Please apply upper forehead scalp seborrheic dermatitis (day 1 = [2176-8-11]). Also, please apply wound left shin overlying fungal infection(day 1 = [2176-8-15]). Thank you! . 20. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal PRN (as needed) needed constipation. 21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) needed headache: Hold somnolence. 22. Heparin drip Heparin IV Sliding Scale (please see included scale): Diagnosis: DVT/A-fib, Patient Weight: 114.76 kg, Initial Bolus: 0 units IVP, Initial Infusion Rate: 1450 units/hr, Target PTT: 60 - 100 seconds, . PTT <40: 4600 units Bolus Increase infusion rate 450 units/hr, PTT 40 - 59: 2300 units Bolus Increase infusion rate 250 units/hr, PTT 60 - 100:, PTT 101 - 120: Reduce infusion rate 250 units/hr, PTT >120: Hold 60 mins Reduce infusion rate 450 units/hr, 23. Insulin sliding scale Glargine 46 units bedtime; Humalog sliding scale per included sliding scale. Discharge Medications: 1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1) Intramuscular Q6H (every 6 hours) needed pruritis. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice day. 9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [12-1] Inhalation every 4-6 hours needed shortness breath wheezing. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn. 13. simvistatin 10mg Qday 14. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times day). 16. Outpatient Lab Work Chem 10 monitor electrolytes creatinine taking lasix 17. Turn reposition back prn limit sit time 1hour time using pressure redistribution cushion. Cleanse skin wound cleanser NS pat dry nad apply aquafor gluteals legs feet daily 18. heel lateral foot ulcer apply thin layer duoderm wound gel, cover dorsum lateral wound adaptic heel gauze followed ABD pad, wrap iwth kerlix change daily 19. headrest occiput frequent repositioning 20. please remove sutures posterior neck tuesday [9-10] [2175] 21. Please start warfarin [2176-9-9] (post op day 10) monitor INR prn 22. check weight Qday Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Cervical myelopathy C1 tumor cervical myelopathy Acute chronic diastolic heart failure Discharge Condition: Stable, afebrile Discharge Instructions: admitted [Hospital1 18] [2176-8-29] worsening upper extremity weakness due spinal tumor. underwent operation remove tumor. also underwent operation decrease pressure spinal cord neck. need staples surgical site [2176-9-10], rehab facility. appointment made follow Dr. [Last Name (STitle) ] 6 weeks. Please return Emergency department fever, chills, difficulty breathing, worsening upper extremity weakness, worsening symptoms. Followup Instructions: 1. [Last Name (STitle) ] LAB [Hospital1 18] [Hospital Unit Name ], [Location (un) ] [Location (un) ] surgery Phone:[Telephone/Fax (1) 1237] Date/Time:[2176-9-26] 3:15 2 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD LM [Hospital Unit Name ], [Location (un) ] [Location (un) ] surgery Phone:[Telephone/Fax (1) 2625] Date/Time:[2176-9-26] 4:15 3. Dr. [Last Name (STitle) 47032] [Name (STitle) ] address: [Doctor First Name ] [Hospital Unit Name ] [Location (un) 470] [Hospital Unit Name ] phone: [Telephone/Fax (1) ] appointment: [2176-10-8] 1:15PM 4. Psychiatry Clinic [Hospital1 18] Psychiatry Clinic Please call bottom number schedule appointment mood sad taking pleasure life: [Telephone/Fax (1) *]	[ "4280" ]
Admission Date: [2142-11-30] Discharge Date: [2142-12-10] Date Birth: [2084-5-2] Sex: Service: MEDICINE Allergies: Percocet / Bactrim Ds / Lisinopril Attending:[First Name3 (LF) 898] Chief Complaint: hypotension Major Surgical Invasive Procedure: none History Present Illness: Mr. [Known lastname 25925] 58 yo w/ multiple sclerosis seizure disorder presented OSH delusions AMS x 2 days. OSH, noted Na 124. history hyponatremia; Na 117 [2-27] mid 130s since then. seen nephrology. OSH, approx 45sec generalized tonic clonic seizure, received 1mg Ativan, transferred ED [Hospital1 18]. also history seizures especially setting infection hyponatremia. unclear seizures without inciting event. currently weaned Keppra Gabapentin started Tegretol. ER, VS were: 97.5; 189/105; 78; 16; 95% 3L. given 2L NS. Given AMS setting infection known chronic UTIs [12-24] indwelling suprapubic catheter neurogenic bladder, blood urine cultures obtained well CXR. urine culture [11-28] grew pseudomonas CXR showed possible infiltrate treated vancomycin cefepime. head CT negative. Past Medical History: MS - since [2119], progressive, quadriplegic, neurogenic bladder suprapubic catheter, restrictive PFT's History Aspiration PNAs Esophageal Ulcer - [12-24] NSAIDs, [2139], small bowel bx negative Recurrent UTIs CHF (EF > 65% moderate LVH '[39]) HTN Legally Blind Social History: married 32 years lives wife home. three children three grandchildren. professor [First Name (Titles) ] [Last Name (Titles) 25949] engineering [University/College 25932], retired disability [2128] spring semester due MS. [Name13 (STitle) ] wheelchair-bound. denies tobacco, alcohol, recreational drug use. personal care assistant. Family History: Father CAD CVA. Mother [Name (NI) 2481] disease. Brother diabetes. Physical Exam: General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema Pertinent Results: [2142-11-29] 10:47PM BLOOD WBC-6.4 RBC-3.99# Hgb-11.8# Hct-33.1* MCV-83# MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-235# [2142-12-10] 05:50AM BLOOD WBC-8.8 RBC-3.54* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-424 [2142-12-7] 05:50AM BLOOD PT-13.6* PTT-34.1 INR(PT)-1.2* [2142-11-29] 10:47PM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-126* K-4.5 Cl-88* HCO3-29 AnGap-14 [2142-11-30] 06:58AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-125* K-4.6 Cl-90* HCO3-28 AnGap-12 [2142-11-30] 12:40PM BLOOD Na-128* [2142-11-30] 09:45PM BLOOD Na-127* [2142-12-1] 07:40AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-131* K-4.0 Cl-93* HCO3-29 AnGap-13 [2142-12-1] 03:00PM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-131* K-4.5 Cl-94* HCO3-30 AnGap-12 [2142-12-2] 05:45AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-133 K-4.6 Cl-95* HCO3-28 AnGap-15 [2142-12-2] 04:10PM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131* K-4.9 Cl-93* HCO3-27 AnGap-16 [2142-12-3] 06:20AM BLOOD Glucose-121* UreaN-21* Creat-1.2 Na-131* K-4.3 Cl-93* HCO3-28 AnGap-14 [2142-12-3] 05:40PM BLOOD Glucose-115* UreaN-25* Creat-1.3* Na-134 K-4.4 Cl-96 HCO3-27 AnGap-15 [2142-12-4] 07:18AM BLOOD Glucose-101 UreaN-23* Creat-0.8 Na-135 K-4.0 Cl-98 HCO3-27 AnGap-14 [2142-12-5] 05:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135 K-3.9 Cl-96 HCO3-26 AnGap-17 [2142-12-6] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-134 K-4.2 Cl-97 HCO3-28 AnGap-13 [2142-12-7] 05:50AM BLOOD Glucose-102 UreaN-21* Creat-0.8 Na-137 K-4.2 Cl-97 HCO3-26 AnGap-18 [2142-12-8] 07:00AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 [2142-12-9] 06:30AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-101 HCO3-28 AnGap-15 [2142-12-10] 05:50AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140 K-4.5 Cl-102 HCO3-26 AnGap-17 [2142-11-29] 10:47PM BLOOD Osmolal-260* [2142-11-30] 12:40PM BLOOD Osmolal-264* [2142-12-8] 07:00AM BLOOD ALT-23 AST-16 LD(LDH)-213 AlkPhos-87 TotBili-0.2 [2142-12-10] 05:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.4 U/A [11-28]: nit +, LE +, WBC 55, RBC 6, Epi 1, bact U/A [11-29]: sm bld, 100 prot/gluc; WBC [1-24], RBC [1-24], Epi [1-24], bact mod U/A [12-2]: sm LE, WBC 10, RBC 2, Epi 1, bact none U/A [12-5]: 30 prot, 10 ket, lg LE; WBC 99, RBC 11, Epi 1, bact U/A [12-6]: 30 prot, mod LE; WBC 22, RBC 8, Epi 3, bact none U/A [12-8]: neg leuk CULTURES: BCx [11-29] x2: neg BCx [12-2] x2: neg UCx [11-28]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML UCx [11-29] pseudomonas UCx [12-2] yeast Ucx [12-5] neg Ucx [12-6] yeast Ucx [12-8] neg c.diff neg x 2 - CXR [12-2]: Patchy opacity left base noted, significance setting low inspiratory volumes uncertain. - CTA [12-2]: PE. Scattered patchy ground-glass opacities may represent expiratory state air trapping. - Renal u/s [12-2]: evidence abscess, hydronephrosis mass - abd xray [12-3]: non-specific bowel gas pattern, stool throughout colon, free air - abd xray [12-4]: Stool- air-filled loops large small bowel consistent ileus. - Liver u/s [12-5]: Hypoechoic right hepatic mass, measuring 4.2 cm size - CT abd: prelim read: Arterially enhancing liver lesion cannot fully characterized, may represent adenoma, FNH, less likely HCC. Brief Hospital Course: 58 yo male w/ progressive multiple sclerosis admitted AMS seizure 45s GTC OSH responded 1mg Ativan. negative head CT found Na level 126. hyponatremic past often caused changes mental status. ED, treated 2L NS concern hypovolemic hyponatremia. time, urine osm 423 serum osm 263. also CXR prelim concern pneumonia cause ADH like effect (the final read neagtive). Neurology consulted AMS seizure felt hyponatremia likely related recent initiation carbamezapine sensory illusions. Carbamezapine known ADH like effect cause hyponatremia. Following discontinuation carbamezapine along fluid restriction, Na increased. several days, pt appeared slightly dehydrated fluid restriction lifted. time discharge, serum Na 140. . past, seizures instigated underlying infection. However, upon admission afebrile leukocystosis. likely source either pneumonia UTI. suprapubic catheter [12-24] neurogenic bladder day prior admission, urine sample grew pseudomonas, bacteria past. also several pneumonias past, likely [12-24] frequent aspirations first CXR concerning lung infiltrate. treated one dose vancomycin cefepime pneumonia. Ultimately, repeat CXR CTA negative pneumonia. . pseudomonal bacteriuria, started ciprofloxacin. urine culture drawn prior abx inititian also grew pseudomonas. afebrile leukocytosis thought may actually colonization opposed infection. However, treated full course cipro complicated UTI. catheter changed cultures remained negative. . admission, pt afebrile hypertensive 180-200. However, shortly arriving floor, episode hypotension 70's systolic. time mentating well, complaints, denied chest pain, headache, visual changes. IVFs given, however hypotension initially respond, however came eventually prior getting ICU. labile blood pressure likely secondary patient's autonomic dysfunction secondary SPMS. considerations infection possible sepsis, however patient continued afebrile. Blood urine cultures negative. monitored ICU 24 hours stable swings BP asymptomatic consistent autonomic dysfunction. Changed clonidine dosing 0.2mg [Hospital1 ] 0.1mg TID. Maintained blood pressure medications home doses. . next day, transferred MICU returned floor. Shortly arrival, developed fever. blood urine cultures sent negative. Pneumonia ruled UTI treated medication appropriate per sensitivities. CTA negative PE. However, started meropenem treated 2 days. still slightly febrile meropenem discontinued concern drug fever. defervesced without treatment. . However, mental status continued fluctuate despite afebrile, obvious source infection, eunatremic. occasionally aggressive would say murdered kidnapped. Neurology reconsulted feel symptoms related keppra think subclinical seizures. continued repetitive shaking moves head conscious able speak episodes. Also, despite Keppra, continued sensory illusions, mostly centered around feeling bowel movement (when actually not). . work source infection source AMS, CTA revealed liver lesion. ultrasound multiphase liver CT describe lesion cannot MRI [12-24] implanted baclofen pump. Mr [Known lastname 25925] family decided biopsy lesion time ruled completely malignancy, although unlikely. work also KUB concerning ileus continued BMs kept regular diet. . Prior discharge, mental status completely returned baseline alert oriented x 3 longer aggressive towards staff. definite etiology elucidated hypothesized could result progression established disease. Medications Admission: BACLOFEN 2,000 mcg/mL Kit -pump BRIMONIDINE Dosage uncertain CARVEDILOL - 25 mg Tablet [Hospital1 ] CARBAMEZAPINE - 100mg [Hospital1 ] CLONIDINE - 0.2 mg Tablet [Hospital1 ] CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream tid FENTANYL - 12 mcg/hour Patch 72 hr FUROSEMIDE - 40 mg Tablet qd IPRATROPIUM-ALBUTEROL prn LACTULOSE prn MINOCYCLINE - 100 mg Tablet [Hospital1 ] MODAFINIL [PROVIGIL] 50 [Hospital1 ] OMEPRAZOLE 20 [Hospital1 ] OXYBUTYNIN CHLORIDE - 15 mg qhs SIMVASTATIN - 40 mg qd TRAVOPROST1 drop L eye day ACETAMINOPHEN prn ASCORBIC ACID 500 [Hospital1 ] BISACODYL hs CALCIUM 500 mg Tid CRANBERRY 475 mg Capsule [Hospital1 ] ERGOCALCIFEROL (VITAMIN D2)400 [Hospital1 ] MINERAL OIL prn OMEGA-3 FATTY ACIDS [Hospital1 ] PSYLLIUM [METAMUCIL] prn SENNA - 8.6 mg Tablet prn Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed. 6. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO QHS (once day (at bedtime)). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day) needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times day). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times day). 12. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times day). 14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 6 days: [2142-12-13]. 16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed. 18. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 19. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inh Inhalation twice day needed. 20. TRAVATAN Z 0.004 % Drops Sig: One (1) Ophthalmic day: Left eye. 21. Cranberry 475 mg Capsule Sig: One (1) Capsule PO twice day. 22. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO twice day. 23. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO twice day. patient allergy listed ACE Inhibitors, therefore discharged ACE Inhibitor. communicated PCP. Discharge Disposition: Home Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: 1. Multiple Sclerosis 2. Urinary Tract Infection, complicated 3. Hyponatremia . Secondary: 1. Chronic Diastolic CHF Discharge Condition: Stable vital signs. Discharge Instructions: admitted altered mental status found low sodium urinary tract infection. started antibiotics urinary tract infection (cipro) complete 2 week course. sodium corrected adjusting medications reducing water intake. . found abnormality liver. CT scan results pending final interpretation. provided phone number schedule appointment [Hospital ] clinic. may necessary reimage liver take biopsy lesion seen CT scan. . medications changed. switched tegratol keppra. Please review recent medication list take medications, discard old medications list. . Please return hospital develop fevers, chills, worsening symptoms. Followup Instructions: 1. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 1575] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 8645] Date/Time:[2143-1-8] 1:30 . 2. [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2143-1-15] 4:00 . 3. [Hospital ] CLINIC [Hospital1 18]: ([Telephone/Fax (1) 2233] Completed by:[2142-12-13]	[ "5990", "5849", "4280", "4019" ]
Admission Date: [2109-8-17] Discharge Date: [2109-10-16] Date Birth: [2054-10-24] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 759] Chief Complaint: B/L ankle fractures, s/p fall Major Surgical Invasive Procedure: [8-18] . 1. Closed reduction left pilon fracture. 2. Application multi-planar external fixator left lower extremity. 3. Closed treatment calcaneus fracture mild amount manipulation. 4. External fixation Right Pilon fracture . [8-30] Adjustment external fixator R pilon fracture . [9-17] ORIF right intra-articular distal tib-fib fracture R History Present Illness: 54 year old Spanish speaking male, US vacation, questionable PMH liver disease presents jumping?falling? window. Per daughter drinking alcohol son reported feeling someone kill him. locked second-story bedroom later found daughter crawling outside. initially seen [Hospital3 ] found opiates cocaine UA emergency department there. transported [Hospital1 18] b/l ankle fractures. Per family, pt confused home. [Name (NI) ], pt aggitated received haldol ativan. later somnolent. EKG demonstrated atrial flutter HRs 110-140's, rate controlled ED IV diltiazem. Patient poor historian, information obtained daughter ROS: + b/l ankle pain, -CP, -SOB, -Abdominal pain Past Medical History: "Gets yellow" High ammonia HTN questionable anginal history depression, family states see psychiatrist Social History: EtOH abuse, polysubstance abuse, one ppd mayn years Urine positive cocaine opiates ED married Daughter involved care Family History: Noncontributory Physical Exam: Vitals: 96.7 140/90 76 16 99% 2L NPO/1000 Physical Exam: General: sleepy arousable, oriented place person, able name months year forwards, backwards, oriented current month/year HEENT: icteric sclerae, dry MM, + c-collar CVS: irregular rate, tachy, murmurs/rubs/gallops appreciated Pulm: CTA b/l, wheezes, rales rhonchi Abd: soft, NT, mild hepatosplenomegaly, +BS Ext: b/l ankle splints, mild bruising b/l knees, - asterixis GU: + foley Pertinent Results: CT C-Spine: negative fracture Left tib/fib: Comminuted fracture calcaneus. Dense sliver bone along medial aspect proximal fibula, seen single view. could represent additional calcification intraosseous ligament, small cortical fracture fragment, foreign body. Right tib/fib: Comminuted, intraarticular, impacted, displaced fractures distal tibia well fracture distal fibula detailed above. . CT bilat LE 1. Comminuted intra-articular distal right tibial fracture. 2. Comminuted distal right fibular fracture displacement. 3. Comminuted left calcaneal fracture. . RUQ U/S: FINDINGS: liver coarse echotexture without evidence focal lesion. gallbladder distended due nonfasting stage. evidence gallstones. evidence intra- extra-hepatic biliary ductal dilatation common duct measures 3 mm. pancreas well visualized due bowel gas. evidence free fluid. main portal vein patent antegrade flow. IMPRESSION: evidence cholecystitis. . Head CT ([8-21]) IMPRESSION: evidence acute intracranial pathology, including sign intracranial hemorrhage. . CXR ([8-21]) previous studies comparison. Low lung volumes. Heart size difficult evaluate semi-upright AP film. could LVH evidence CHF lungs clear. Questionable slight impression right margin tracheal air column better evaluated standard PA lateral chest films condition permits. . Chest CT ([8-23]): 1. juxtatracheal mass left upper lobe lesion questioned chest radiograph report. 2. Three foci ground glass, right upper lobe, detectable routine radiographs, nonspecific finding. Six- month CT follow recommended look change, bronchoalveolar cell carcinoma, though unlikely, cannot excluded. 3. Borderline size mediastinal hilar lymph nodes checked followup CT. 4. Mild atherosclerotic coronary artery calcification. Chest CTA ([8-24]): 1. pulmonary embolism. 2. Relatively unchanged appearance multiple ill-defined opacities tiny nodules right upper lobe. Follow-up stated examination 1 day prior recommended. 3. New foci opacification present lung bases compared examination one day prior likely related aspiration. Layering debris present within right main stem bronchus suggestive aspiration well. Clinical correlation recommended. 4. Recommend advancing NG tube least 4-5 cm. current position elevates risk aspiration. . CT RLE contrast ([8-24]): IMPRESSION: Comminuted distal tibial fibular fractures intra- articular involvement tibial plafond lateral displacement talus respect tibia. Posterior displacement distal fibular fragment. . CT LLE without contrast ([8-24]) Comminuted left calcaneal fracture. Lentiform area fluid attenuation skin posterolateral aspect left foot. significance latter finding uncertain, may due skin blister possibly dressing material within cast. Clinical correlation requested. . CXR ([8-26]) 1. NG tube could advanced several centimeters standard positioning, described prior exams. 2. New perihilar opacities, likely due acute aspiration superior segments. . Head CT ([9-3]) IMPRESSION: evidence hemorrhage CT evidence acute infarct. . CT abd/pelvis ([9-22]): IMPRESSION: CT evidence pyelonephritis abscess within abdomen/pelvis. . CT LLE without contrast ([9-26]) 1. Markedly comminuted fracture calcaneus wide distraction dispersal fracture fragments above. 2. Non-displaced fractures sustentaculum tali middle facet talus. 3. fracture identified medial malleolus. 4. Non-displaced fractures anterior aspect inferior aspect lateral malleolus. 5. Non-displaced fracture cuboid. 6. fracture identified navicular. 7. fractures identified within remainder mid foot forefoot. 8. Lateral subluxation peroneal tendons respect fibula. 9. Probable tear anterior talofibular ligament. . Echo ([9-26]): left atrium mildly dilated. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%) Transmitral tissue Doppler imaging suggests normal diastolic function, normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. estimated pulmonary artery systolic pressure normal. pericardial effusion. IMPRESSION: Normal global regional biventricular systolic function. Brief Hospital Course: course hospitalization, pt put CIWA scale EtOH withdrawal given thiamine, folate multivitamin, AFib RVR initially treated metoprolol, diltiazem, high ammonia levels treated lactulose. b/l ankle fractures followed orthopedics. patient severely agitated one occassion hospitalization, requiring three codes puples called well requiring restraints protection patient staff. patient originally sent floor MICU delirium unknown cause severe agititation. required increased amounts sedation returned floor NG tube placed. returned floor, patient required less sedation, taken benzodiazipines intermittently needed restraints. patient remained somnolent delerious. pulled NG tube. also febrile rhoncorous floor. initially treated vancomycin flagyl, changed azithro/ceftriaxone/flagyl. scheduled return revision right external fixation. preop holding, found hypoxic sent MICU. MICU COURSE: Morning [8-28], patient scheduled return revision externally fixated RLE. Upon transport PACU, patient became somnolent reported "agonal breathing". O2 sats 83% 2LNC NRB applied O2 sats 100%. BP 90s/60s, HR 80s, RR 17-19. ABG drawn: 7.38/58/90. stay MICU, patient coughed large amount thick sputum improved respiratory status. Surgery postponed patient transferred MICU monitoring. MICU, respiratory status remained stable Sp02 high 90s room air. Pt hemodynamically stable chronic a-flutter. Called floor [8-29]- intensive care needs identified. MICU, patient started Zosyn restarted Vancomycin wiht marked improvement respiratory status. Within days returning floor, Vancomycin zosyn stopped CXR showed resolution questionable aspiration pneumonia - felt likely pneuomonitis resolved. . MICU, patient's delirium started improve, worsened returned removal external fixation. developed fevers 102F post-operatively likely worsened delirium. Source fevers unclear - note patient recently developed VRE urine infectious disease feel active infection. received three days antibiotics (daptomycin linezolid). stopped became afebrile delirium began lift. . #Aggitation mostly controlled haldol. Zyprexa tried two weeks seem help acute aggitation. QTc monitored patient antipsychotics stable approximately 420-440msec. Overall etiology delirium remained unclear thought multifactorial due part chronic alcohol use, hepatic encephalopathy, benzodiazepine use, post-operative delririum. Although spanish-speaking 1:1 sitters interpreters employed much possible, language also likely contributed persistance delirium. Delirium completely resolved patient restraint sitter free. haldol stopped. past period etoh withdrawal. recommended patient follow alcohol abuse counseling. . #Afib/flutter febrile, afib/flutter complicated frequent episodes rapid ventricular rate. controlled IV metoprolol needed also increasing PO metoprolol diltiazem. Treating fever tylenol also seemed help. briefly put therapeutic lovenox atrial fibrillation, stopped felt eligible CHADS criteria also high fall risk. Patient transitioned beta blockers placed Diltiazem 120mg daily. . #Urinary retention patient failed several voiding trials. also pulled foley several occasions, causing hematuria. Intermittent straight catheterization tried reduce infection risk long-term indwelling foley. However given delirium aggitation untenable. resolved reductions haldol. Patient able void freely own. History VRE urine culture, signs infection, dyruria, increased urinary frequency. evidence based literature clinical indications treat asymptomatic bacteuria time. . #Fractures patient followed orthopedics admission. L ankle fractures treated casting, however repeat plain films CT scan 4-6 weeks post-op showed fractures initially visualized. Orthopedics felt casting still appropriate indication surgery. R pilon fracture managed initially external fixation system skin breakdown making internal fixation difficult. One month hospitalization ex-fix removed tibial fibular plates placed. remain Non-weight bearing total one month hospital discharge. Patient completed necessary course lovenox.He follow appointment scheduled orthopaedic surgeon Dr. [Last Name (STitle) ] [11-28] 1030am, [Hospital3 ] [Hospital Ward Name ], [Location (un) 1385] [Hospital Ward Name 23] building. . Transfer [Hospital ] Rehab Hospital. Medications Admission: Diltiazem 180 mg one daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times day) needed. Disp:30 Tablet, Chewable(s) Refills:0 5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:1 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) needed. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Primary: 1) Bilateral Lower Extremity fractures a. Closed left tibial plafond fracture/pilon fracture. b. Dislocation left tibiotalar joint. c. Right calcaneus fracture, intra-articular 2) Persistent agitated delirium ?????? resolved 3) Aspiration Pneumonitis - resolved 4) Alcoholism ?????? continuous 5) Delirium Tremens 6) Polysubstance Abuse (cocaine, opiates, alcohol) 7) Atrial Fibrillation/Atrial Flutter 8) Abnormal CT chest ?????? follow-up ([2111-1-5]) recommended 9) Liver Failure ?????? presumed secondary alcoholism (No evidence HBV HCV infection) a. Thrombocytopenia presumed secondary thrombopoitin deficiency. evidence splenomegaly imaging. 10) Elevated AFP level ?????? etiology yet undetermined Secondary: 1) Hypertension 2) Urinary retention ?????? resolved 3) Bactiuria ?????? asymptomatic, colonized Vancomycin resistant enterococcus Contact information: [First Name8 (NamePattern2) ] [Known lastname 1794] (daughter): [Telephone/Fax (1) 74301] [Female First Name (un) 74302] & [First Name9 (NamePattern2) 74303] [Known lastname 1794](son) cell [Telephone/Fax (1) 74304] Follow-up: 1) Repeat CT scan chest [2111-1-5] f/u 3 foci ground glass RUL well borderline mediastinal hilar lymphadenopathy 2) Assess etiology elevated alpha-fetoprotein 3) evaluate etiology pancyctopenia ?????? consider bone marrow aspirate well HIV testing Discharge Condition: Stable, Non-weight bearing legs one month starting [10-15] Discharge Instructions: transferred [Hospital1 18] emergency room large fall. found bilateral ankle fractures. CT scan head show acute bleed. came emergency room heart rate fast, given medications help slow down. . [8-18] operation left leg heel ankle fracture, several pins placed left leg. left leg casted. . [8-30] operation R tibula fibula fracture stabilized leg externally. . [9-17] operation right tibula fibula screws placed help leg heal. . hospital stay. confused placed many psychiatric medications, became agitated times,and restrained times. resolved longer psychiatric medications. . hospital developed breathing problems. [Name (NI) ] spent time intensive care unit, worry might pneumonia, started antibiotics, breathing problems improves, chest xray improved. thought pneumonia antibiotics normal. . also found bacteria urine called VRE, having, burning urination. infectious disease doctors thought bacteria treated. . transferred rehab facility. important rehab facility you, follow get counseling problems alcohol abuse. . follow appointments schedule orthopaedics new primary care physician. [Name10 (NameIs) ] important follow appointments. . also important put weight legs next month. Please return hospital emergency room condition worsens way. abnormal chest x-ray/CT scan repeated [2111-1-5] make sure lung cancer. blood counts low stable hospitalization. see Hematologist (Blood Doctor) consider testing HIV. elevation marker blood called AFP (alpha fetoprotein). significance know. may related underlying liver disease evaluated specialist. absolutely refrain use alcohol, cocaine illicit drugs explicitly prescribed physician. Ten??????as una exploraci??????n anormal [Doctor First Name ] pecho x-ray/CT [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (un) 7214] esto repetido en diciembre de [2110] para cerciorarse de t?????? [Last Name (un) 7214] pulm??????n c??????ncer. Tus cuentas de sangre [Doctor First Name ] [First Name9 (NamePattern2) 74305] [Last Name (un) ] [First Name9 (NamePattern2) 74306] [Last Name (un) 33761] tu hospitalizaci??????[Initials (NamePattern4) ] [Last Name (NamePattern4) 7213] [Last Name (un) ] un hemat??????logo (el doctor [Last Name (Titles) ] [Last Name (Prefixes) 74307]) sobre esto considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [Name Prefix (Prefixes) ] [Last Name (Prefixes) 74308]??????n de esto es saber. Puede ser relacionado con tu enfermedad [Doctor First Name ] higado [First Name9 (NamePattern2) 74309] [Last Name (un) ] debe ser m??????s futuro evaluado por un especialista. [Last Name (un) 7213] refrenarse absolutamente [Doctor First Name ] uso adicional [Doctor First Name ] alcohol, de [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]??????na de cualquier droga il??????cita prescritos expl??????citamente ti por un m??????dico. Followup Instructions: Ten??????as una exploraci??????n anormal [Doctor First Name ] pecho x-ray/CT [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (un) 7214] esto repetido en diciembre de [2110] para cerciorarse de t?????? [Last Name (un) 7214] pulm??????n c??????ncer. Tus cuentas de sangre [Doctor First Name ] [First Name9 (NamePattern2) 74305] [Last Name (un) ] [First Name9 (NamePattern2) 74306] [Last Name (un) 33761] tu hospitalizaci??????[Initials (NamePattern4) ] [Last Name (NamePattern4) 7213] [Last Name (un) ] un hemat??????logo (el doctor [Last Name (Titles) ] [Last Name (Prefixes) 74307]) sobre esto considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [Name Prefix (Prefixes) ] [Last Name (Prefixes) 74308]??????n de esto es saber. Puede ser relacionado con tu enfermedad [Doctor First Name ] higado [First Name9 (NamePattern2) 74309] [Last Name (un) ] debe ser m??????s futuro evaluado por un especialista. [Last Name (un) 7213] refrenarse absolutamente [Doctor First Name ] uso adicional [Doctor First Name ] alcohol, de [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]??????na de cualquier droga il??????cita prescritos expl??????citamente ti por un m??????dico. Please follow Dr. [Last Name (STitle) ] orthopedic surgery appointment scheduled [2112-11-28]:30 am, [Location (un) 1385] [Hospital Ward Name 23] building [Hospital Ward Name ] [Hospital1 771]. Please call [Telephone/Fax (1) 9769] would like change appointment. Please follow new primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 15259] [2109-11-19] 3pm [Hospital Ward Name 23] Center [Location (un) ] [Hospital Ward Name 516] [Hospital1 1170]. abnormal chest x-ray/CT scan repeated [2111-1-5] make sure lung cancer. blood counts low stable hospitalization. see Hematologist (Blood Doctor) consider testing HIV. elevation marker blood called AFP (alpha fetoprotein). significance know. may related underlying liver disease evaluated specialist.	[ "4019", "5990" ]
Admission Date: [2170-9-19] Discharge Date: [2170-9-25] Date Birth: [2099-5-27] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea exertion fatigue Major Surgical Invasive Procedure: [2170-9-19] Coronary artery bypass graft x 4 (Left internal mammary artery diagonal, saphenous vein graft left anterior descending, saphenous vein graft obtuse marginal, saphenous vein graft posterior descending artery) History Present Illness: 71 year old male presented PCP [Name Initial (PRE) ] routine visit complaints recent onset fatigue, dyspnea exertion, exertional throat discomfort left arm. denied rest pain reports discomfort dyspnea occur minimal activities showering. found hypertensive started Atenolol 25mg daily. EKG normal sent nuclear stress test. underwent nuclear stress test [2170-8-1] revealed inferolateral ischemia moderate inferior, inferolateral, posterolateral perfusion abnormality. refereed cardiac catheterization. referred cardiac surgery revascularization. Past Medical History: Hypertension Right rotator cuff tear Compound fracture left arm/plated child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair left arm fracture, plated Social History: Race:Caucasian Last Dental Exam:"a long time ago", recall Lives with:Wife Contact:[Name (NI) ] (wife) Phone #[Telephone/Fax (3) 74913] Occupation:self employed painter Cigarettes: Smoked [x] Tobacco use:denies ETOH: stopped drinking [12-20] Illicit drug use:denies Family History: premature coronary artery disease Physical Exam: Pulse: 56 Resp:13 O2 sat:97/RA B/P Right:173/82 Left:164/76 Height:5'9" Weight:200 lbs General: NAD, WG, WN Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: bruits Pertinent Results: [2170-9-25] 06:35AM BLOOD WBC-10.9 RBC-2.94* Hgb-9.3* Hct-26.3* MCV-89 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-261 [2170-9-24] 06:20AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.1* Hct-28.7* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.2 Plt Ct-197 [2170-9-25] 06:35AM BLOOD Na-139 K-4.0 Cl-99 [2170-9-24] 06:20AM BLOOD Glucose-118* UreaN-26* Creat-0.9 Na-139 K-4.0 Cl-98 HCO3-31 AnGap-14 [2170-9-23] 05:00AM BLOOD UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-99 Brief Hospital Course: Mr. [Known lastname ] day admit [9-19] brought operating room underwent Coronary artery bypass graft x4 (left internal mammary artery diagonal saphenous vein grafts left anterior descending, obtuse marginal, posterior descending arteries) Dr.[First Name (STitle) ]. CARDIOPULMONARY BYPASS TIME:104 minutes. CROSS-CLAMP TIME:93 minutes. Please see operative report surgical details. Following surgery transferred CVICU intubated sedated critical stable condition. Later day weaned sedation, awoke neurologically intact extubated without incident. weaned pressor support beta blocker/Statin/Aspirin diuresis initiated. Chest tubes epicardial pacing wires removed per protocol. POD#1 transferred step-down unit monitoring. Physical Therapy consulted evaluation strength mobility. postoperative course developed atrial fibrillation treated beta blockers amiodarone. Anticoagulation initiated Coumadin. developed phlebitis IV Amio placed course Keflex x 7 days. slowly improving. pulmonary status waxed waned strong productive cough wheezing, improved time discharge. continued nebulizer treatments. CXR showed small bilateral pleural effusions atelectasis, infiltrate density. pulmonary status slowly improved day discharge. POD 4 developed tender erythematous right knee treated colchicine presumed gout. improved time discharge colchicine discontinued. POD 6 afebrile, ambulating assistance, tolerating full po diet wounds healing well. POD 6 discharged Lifecare Center [Location 15289] stable condition. follow appointments advised. Medications Admission: ATENOLOL 25 mg Daily ASPIRIN 325 mg daily FISH OIL-DHA-EPA 1,200 mg-144 mg-216 mg Daily MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [A THRU Z HIGH POTENCY] 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily NAPROXEN SODIUM [ALEVE]PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) needed constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed pain/temp. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours needed pain. 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times day): x 1 week 200 [Hospital1 ] x 1 week 200 mg daily directed caridologist. 8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO day. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) needed coughing . 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) 7 days: right arm phlebitis. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 14 days. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO day 14 days. 17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO (Once): Give 4 mg [9-26] directed INR goal 2.0-2.5 fib. Discharge Disposition: Extended Care Facility: Life Care Center [Location 15289] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 4 Past medical history: Hypertension Right rotator cuff tear Compound fracture left arm/plated child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair left arm fracture, plated Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed oral analgesia Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Females: Please wear bra reduce pulling incision, avoid rubbing lower edge Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments Surgeon: Dr. [First Name (STitle) ] [10-29] 1:15pm, #[Telephone/Fax (1) 170] Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] [9-25] 2:00pm Please call schedule appointments Primary Care Dr. [Last Name (STitle) ]. Nikolaos Michalacos [4-17] weeks Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Labs: PT/INR Coumadin ?????? indication atrial fibrillation Patient given 4 mg Coumadin [2170-9-25] Goal INR 2.0-2.5 First draw [2170-9-26] Please arrange follow PCP cardiologist prior discharge rehab [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2170-9-25]	[ "4019" ]
Admission Date: [2199-12-3] Discharge Date: [2199-12-19] Date Birth: Sex: Service: CHIEF COMPLAINT: Hypoxia HISTORY PRESENT ILLNESS: 33 year old male significant past medical history initially presented [Company 191] Outpatient Clinic [11-27] four days high fevers (103 degrees F), nonproductive cough, malaise, diffuse myalgias, mild resting dyspnea, exposure ill contacts. [2199-11-27] vital signs office temperature 99.5, blood pressure 120/85, heartrate 113 respiratory rate 20, oxygen saturation 89% room air. Weight 238 lbs. Nonspecific pulmonary examination appreciated time. prescribed Levaquin 500 mg p.o. q.d. discharged home. represented outpatient [Hospital 191] Clinic [2199-12-3] complaining persistent fever 102 degrees F, weakness, bilious emesis, worsening dyspnea, nonproductive cough. Vital signs office temperature 97.3, blood pressure 108/70, respiratory rate 20, heartrate 108, oxygen saturation 70% room air. wheezes noted examination. given 1 gm Ceftriaxone sent Emergency Department received normal saline 1 gm Vancomycin. denied pleuritic chest pain. risk factors human immunodeficiency virus. denies history seizure disorder, alcohol use, recent somnolence, symptoms gastroesophageal reflux disease. transferred Intensive Care Unit arrival. PAST MEDICAL HISTORY: significant past medical history surgical history. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: Levofloxacin 500 mg p.o. q.d. SOCIAL HISTORY: Originally [Male First Name (un) 1056]. bus driver, lives wife daughter, alcohol, elicit drug use. Rare alcohol use. FAMILY HISTORY: Father diabetes mellitus. PHYSICAL EXAMINATION ADMISSION: General, moderately obese, sitting bed, accessory muscle use. Vital signs, temperature 99.0, heartrate 92, blood pressure 137/74, respiratory rate 16, oxygen saturation 100% 100% nonrebreather. Head, eyes, ears, nose throat, pupils equal, round reactive light, extraocular muscles intact, anicteric, oropharynx clear, fair dentition. Neck, lymphadenopathy. Chest, rhonchi, right greater left, crackles, wheezes. Normal E ratio, egophony, fremitus, dullness percussion. Cardiac, regular rate rhythm, murmurs, rubs gallops. Abdomen, obese, normoactive bowel sounds, nontender, nondistended, masses. Neurological, cranial nerves II XII grossly intact. Alert oriented times three. Conversant appropriately. Strength 5/5 extremities. LABORATORY DATA: Laboratory findings admission revealed white blood cell count 8.4, 73% neutrophils, 0 bands, 19 lymphocytes, 6 monocytes, hematocrit 43.8, platelets 104, MCV 83, RDW 13.0, sodium 137, potassium 3.4, chloride 92, bicarbonate 29, BUN 13, creatinine 0.8, glucose 129. Arterial blood gases 100% nonrebreather, PH 7.49, carbon dioxide 39, oxygen 77. Imaging: [2199-11-27], chest x-ray, normal, acute cardiopulmonary process. Chest x-ray [2199-12-3], (on admission), patchy right upper lobe, right middle lobe infiltrate diffuse right greater left interstitial pattern, normal mediastinum, effusion. HOSPITAL COURSE: 33 year old male past medical history originally admitted Intensive Care Unit hypoxia, bilateral pneumonia, received Ceftriaxone Azithromycin, Doxycycline added since parakeet home (he also rats home). underwent bronchoscopy computed tomographic angiography thorax demonstrated right middle lobe right lower lobe pulmonary emboli question infarction. subsequently heparinized. human immunodeficiency virus test negative. received Bactrim steroids days stopped human immunodeficiency virus test came back negative. hypercoagulability workup pending arrived floor stable condition. arrival floor clinically improving heparin drip, Ceftriaxone, Azithromycin, Doxycycline. studies obtained Intensive Care Unit included [First Name8 (NamePattern2) ] [Doctor First Name ] negative, ANCA negative, hepatitis panel negative. LENIS demonstrated deep vein thrombosis, thrombosis right lesser saphenous vein, echocardiogram obtained well [12-6], demonstrated ejection fraction 50%, mildly dilated right ventricle mild tricuspid regurgitation. chest computerized tomography scan mentioned [12-4] demonstrated multiple small pulmonary emboli (right lower lobe right middle lobe) bilateral atypical pneumonias. Workup organism said pneumonia undertaken. negative viral culture, negative Chlamydia, negative leptospirosis, negative C. Psittaci negative mycoplasmas. Blood cultures negative well. maintained Azithromycin completed 14 day course pneumonia. Doxycycline withdrawn. completed ten day course Ceftriaxone. Regarding pulmonary emboli, remained hemodynamically stable heparin drip throughout admission. repeat computerized tomography scan thorax demonstrated bilateral expanded heterogenous soft tissue densities within rectus abdominis muscle ? hematomas, partial resolution bilateral perihilar ground-glass opacities, left SVC, however, pulmonary emboli. Given discrepancy [12-4] [12-11], computerized tomography scans, would difficult prove pulmonary emboli [12-4] film. decision anticoagulate three six months pursue evaluation made. Regarding anticoagulation workup, patient positive anticardiolipin IgM (46.9). intermediate range value. IgG anticardiolipin value 1.6. patient normal PTT admission. make diagnosis anticardiolipin syndrome single value, finding stands nonspecific, however, anticardiolipin panel repeated six weeks. patient subsequently continued anticoagulation pulmonary emboli. heparin drip discontinued discharge bridged Coumadin Lovenox. Regarding rectus hematomas noted computerized axial tomography scan, finding commonly seen setting anticoagulation. patient concurrently fevers maximally 101 degrees F. concern perhaps fevers may attributable hematoma local infection thereabouts. started Clindamycin conjunction Infectious Disease Consult Service's recommendations. completed ten day course Clindamycin. Finally, patient noted drop hematocrit anticoagulation. guaiac negative. source bleed identified. likely bled abdominal hematoma attributing drop hematocrit. patient also intermittently hyponatremic stay, likely secondary syndrome inappropriate antidiuretic hormone secondary thoracic processes (namely bilateral pneumonia, pulmonary embolisms) admission. DISCHARGE DIAGNOSIS: 1. Bilobar pneumonia atypical fevers 2. Pulmonary embolus 3. Rectus hematoma 4. Anticardiolipin antibody IgM positive 5. Hyponatremia 6. Anemia FOLLOW UP: patient follow primary provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] week following discharge. MEDICATIONS DISCHARGE: discharged Lovenox bridge Coumadin. also discharged Clindamycin complete ten day course. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Name8 (MD) 17844] MEDQUIST36 D: [2200-5-7] 17:14 T: [2200-5-7] 19:08 JOB#: [Job Number ]	[ "486", "2859" ]
Admission Date: [2140-11-11] Discharge Date: [2140-11-24] Service: CARDIOTHORACIC HISTORY PRESENT ILLNESS: patient scheduled admission aortic aneurysm repair. 81 year old woman history hypertension, recurrent pericarditis pleuritis requiring percutaneous drainage [2137]. echocardiogram [2137-12-13], showed normal left ventricular function dilated aortic root 48mm, mildly thickened aortic valve mild aortic regurgitation. Follow-up [2140-9-12], echocardiogram showed ejection fraction 60% dilated aortic root 55mm, mild aortic sclerosis, mild aortic regurgitation, bilateral atrial enlargement. Cardiac catheterization done [2140-10-26], showed ejection fraction 80% normal wall motion, severe aneurysmal dilatation ascending aorta arch, recurrent dilatation descending aorta dissection, 1+ aortic regurgitation, normal coronaries. PAST MEDICAL HISTORY: 1. Hypertension. 2. Raynaud's disease. 3. Phlebitis. 4. Osteoporosis. 5. Tonsillectomy. 6. Spinal fusion. 7. Umbilical hernia repair. 8. Appendectomy. 9. Cholecystectomy. 10. Total abdominal hysterectomy. MEDICATIONS ADMISSION: 1. Metoprolol 100 mg twice day. 2. Hydrochlorothiazide 25 mg daily. 3. Lisinopril 10 mg daily. 4. Enteric Coated Aspirin 81 mg daily. 5. Centrum Silver one daily. 6. Calcium 600 daily. 7. Nexium 40 mg daily. ALLERGIES: Stated allergy Codeine caused bad abdominal cramps adhesive tape causes rash. SOCIAL HISTORY: patient lives home husband. [Name (NI) 1139] one half pack per day times eighteen years, quit forty-five years ago. Alcohol one drink per day, none times past four weeks. PHYSICAL EXAMINATION: time preadmission testing, heart rate 74 beats per minute, blood pressure 148/80, respiratory rate 18, oxygen saturation 96% room air, height four feet eleven inches, weight 106 pounds. general, appears younger stated age acute distress. Skin - breaks rashes. Head, eyes, ears, nose throat - pupils equal, round, reactive light accommodation. Extraocular movements intact. Pharynx clear. neck supple jugular venous distention, bruits, carotid pulses 2+ bilaterally. chest clear auscultation bilaterally. heart regular rate rhythm, murmurs, rubs gallops. abdomen soft, nontender, nondistended, positive bowel sounds, hepatosplenomegaly, well healed surgical scars. Extremities without cyanosis, clubbing edema. Left upper extremity nodularity old intravenous site near left wrist. varicosities lower extremities. Neurologically, patient alert oriented times three, grossly intact. Pulses - femoral indicated. Dorsalis pedis 1+ bilaterally. Posterior tibial detected. Radial 2+ bilaterally. carotid bruits bilaterally. HOSPITAL COURSE: stated previously, patient direct admission operating room [2140-11-11], time underwent supracoronary ascending aortic graft resuspension aortic valve. Please see operative report full details. patient tolerated operation well transferred operating room Cardiothoracic Intensive Care Unit. Circ arrest time eleven minutes. time transfer, patient Milrinone 0.4 mcg/kg/minute, Amiodarone 1 mg per minute, Neo-Synephrine dose indicated Propofol, also dose indicated. patient well immediate postoperative period. anesthesia reversed. weaned ventilator. morning postoperative day one, successfully extubated. postoperative day number one, cardioactive medications begun weaning beginning Amiodarone Milrinone. postoperative day two, patient maintained minimal amounts Amiodarone, Milrinone Nipride. postoperative day two, patient's Milrinone discontinued. Amiodarone changed p.o. Nipride discontinued initiation beta blockade. chest tubes removed. maintained Cardiothoracic Intensive Care Unit monitoring hemodynamic pulmonary status. postoperative day three, patient continued well. remained hemodynamically stable. transferred Cardiothoracic Intensive Care Unit [Hospital Ward Name 121] Two continuing postoperative care cardiac rehabilitation. floor, noted patient gone sustained atrial fibrillation heart rate 100 110, hemodynamically tolerated well. seen electrophysiology service maintained p.o. Lopressor well p.o. Amiodarone continued monitored floor. next two days, patient atrial fibrillation. remained hemodynamically stable throughout periods. postoperative day five, noted patient drop hematocrit guaiac positive stools. seen gastroenterology service. time, also transferred back Cardiothoracic Intensive Care Unit close monitoring. patient underwent KUB read normal. also stools sent Clostridium difficile negative. empirically started Flagyl time. patient remained Intensive Care Unit next several days monitor gastrointestinal status make sure guaiac positive stools. postoperative day seven, transferred floor continuing postoperative care. Prior transfer Intensive Care Unit, noted patient left upper extremity swelling. underwent ultrasonography upper extremities time rule thrombosis. Ultrasound showed right internal jugular cephalic thrombus. Following transfer, vascular service consulted recommended oral anticoagulation Coumadin, begun time. next several days, exception intermittent atrial fibrillation, patient uneventful hospital course. seen electrophysiology service given episodes atrial fibrillation, last episode lasting greater 24 hours. patient additionally begun Heparin given duration episode atrial fibrillation. patient scheduled direct current cardioversion, however, prior cardioversion, patient spontaneously converted normal sinus rhythm. postoperative day twelve, decided patient remained rate controlled rhythm next 24 hours, would stable ready transferred rehabilitation. time dictation, patient's physical examination follows; vital signs revealed temperature 98.2, heart rate 71, sinus rhythm, blood pressure 147/68, respiratory rate 20, oxygen saturation 98% room air. Weight preoperatively 50 kilograms transfer rehabilitation 53 kilograms. Laboratory data [2140-11-23], white blood cell count 11.7, hematocrit 34.5, platelet count 219,000. Prothrombin time 15.0, partial thromboplastin time 25.0 Heparin off. INR 1.5. Sodium 129, potassium 4.8, chloride 95, CO2 29, blood urea nitrogen 16, creatinine 0.8, glucose 183. patient alert oriented times three, moves extremities, follows commands. Respiratory revealed scattered rhonchi. Cardiac regular rate rhythm murmur. sternum stable incision Steri-strips open air, clean dry. abdomen soft, nontender, nondistended positive bowel sounds. Extremities warm well perfused edema. Right upper arm minimal edema resolving last several days. MEDICATIONS DISCHARGE: 1. Colace 100 mg p.o. twice day. 2. Amiodarone 200 mg p.o. three times day times one week 200 mg p.o. daily times one month. 3. Metoprolol 100 mg twice day. 4. Lasix 20 mg daily times ten days. 5. Potassium Chloride 20 meq daily times ten days. 6. Prilosec 40 mg p.o. daily. 7. Heparin 600 units per hour keep partial thromboplastin time 40 60 INR therapeutic. 8. Warfarin maintain INR 2.0 2.5. patient received 2 mg Coumadin two days prior discharge Coumadin one day prior discharge 2 mg Coumadin night discharge. check INR morning dose Coumadin day transfer rehabilitation center. CONDITION DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Status post supracoronary ascending aortic graft resuspension aortic valve. 2. Hypertension. 3. Raynaud's disease. 4. Phlebitis. 5. Osteoporosis. 6. Status post tonsillectomy. 7. Status post spinal fusion. 8. Status post umbilical hernia repair. 9. Status post inguinal hernia repair. 10. Status post appendectomy. 11. Status post cholecystectomy. 12. Status post total abdominal hysterectomy. DISCHARGE STATUS: patient discharged [Location 50742]. FO[Last Name (STitle) ]P: follow-up Dr. [First Name (STitle) ] two three weeks follow-up Dr. [Last Name (STitle) 1159] one month follow-up Dr. [Last Name (Prefixes) ] one month. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2140-11-23] 16:44 T: [2140-11-23] 18:31 JOB#: [Job Number 50743]	[ "4019" ]
Admission Date: [2164-4-23] Discharge Date: [2164-4-27] Date Birth: [2096-1-7] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1406] Chief Complaint: Chest pain shortness breath Major Surgical Invasive Procedure: [2164-4-23] Coronary artery bypass grafting x3 left internal mammary artery left anterior descending artery reverse saphenous vein graft posterior descending artery obtuse marginal artery. History Present Illness: 68 year old male history MI 25 years ago. treated medication since then. well years 3 weeks ago started notice diaphoresis, shortness breath right sided chest discomfort occurred exertion yard work taking trash. symptoms resolve rest. also one episode chest pain, diaphoresis back pain occurred rest large meal. episode lasted little longer episodes prompted patient contact Dr. [Last Name (STitle) 1270]. sent stress echo abnormal referred cardiac catheterization. found three vessel disease referred cardiac surgery revascularization. Past Medical History: diabetes type II -diagnosed [2160]; controlled oral agents hyperlipidemia hypertension MI [2138] psoriasis Social History: Race:Caucasian Last Dental Exam:[1-/2164] Lives with:Wife Contact:[Name (NI) ] (wife) Phone #[Telephone/Fax (1) 90854] Occupation:Retired FDA field investigator consultant Cigarettes: Smoked [] yes [x] Hx:smoked 2ppd 28 years quit [2138] Tobacco use:denies ETOH: < 1 drink/week [x] [12-27] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- unknown-adopted Physical Exam: Pulse:61 Resp:16 O2 sat:100/RA B/P Right:138/86 Left:135/74 Height:6'2" Weight:230 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _____ Varicosities: (L)LE superficial varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit -none appreciated, pulses Right:2+ Left:2+ Pertinent Results: [2164-4-23] Echo: PRE-BYPASS: spontaneous echo contrast seen body left atrium left atrial appendage. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity size top normal/borderline dilated. mild regional left ventricular systolic dysfunction hypokinesis basal distal inferoseptal anteroseptal walls. Overall left ventricular systolic function mildly depressed (LVEF= 50-55 %). Right ventricular chamber size free wall motion normal. simple atheroma aortic arch. simple atheroma descending thoracic aorta. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. pericardial effusion. Dr. [Last Name (STitle) ] notified person results time surgery. POST-BYPASS: patient sinus rhythm. patient inotropes. Biventricular function unchanged. Mitral regurgitation unchanged. aorta intact post-decannulation. [2164-4-27] 04:44AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.8* Hct-28.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.0 Plt Ct-323 [2164-4-27] 04:44AM BLOOD Plt Ct-323 [2164-4-27] 04:44AM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-139 K-3.8 Cl-102 HCO3-28 AnGap-13 [2164-4-27] 04:44AM BLOOD Mg-2.3 COMPARISON: [2164-4-25] 10:45 a.m. FINDINGS: noted previously, similar-sized left apical pneumothorax. left chest tube removed interim. Left basilar atelectasis remains. cardiac silhouette mediastinal contours unchanged. Median sternotomy wires unchanged. IMPRESSION: Unchanged small left apical pneumothorax, status post left chest tube removal. Brief Hospital Course: Mr. [Known lastname ] 68 yr old male history MI developed worsening chest pain, underwent cath revealed significnat CAD. seen cardiac surgery service accepted CABG. day admit [4-23] brought directly operating room underwent coronary artery bypass graft x 3. Please see operative note surgical details. Following surgery transferred CVICU invasive monitoring stable condition. Later day weaned sedation, awoke neurologically intact extubated. weaned Neo overnight started beta-blocker POD#1. diuresed towards preoperative weight. POD#1 transferred step unit monitoring. continued progress well floor. Physical Therapy consulted evaluation strength mobility. remainder postop course essentially uneventful. cleared discharge home VNA services POD#4. Follow-up appts arranged. Medications Admission: ATENOLOL 50 mg Daily LIPITOR 20 mg Daily PLAVIX 75 mg Daily (started [2164-4-14]), LD [4-17] DILTIAZEM HCL 240 mg Daily ENALAPRIL MALEATE takes 10mg qam, 5mg qhs HYDROCHLOROTHIAZIDE 25 mg Daily METFORMIN 1,000 mg [Hospital1 ] NITROGLYCERIN 0.4 mg Tablet PRN Aspirin 325mg Daily Centrum Silver Multivitamin 1 tablet daily Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO day 2 weeks. Disp:60 Tablet Extended Release(s) Refills:2 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain. Disp:40 Tablet(s) Refills:0 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:1 Refills:2 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). Disp:120 Tablet(s) Refills:2 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: diabetes type II -diagnosed [2160]; controlled oral agents hyperlipidemia hypertension MI [2138] psoriasis Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed oral analgesia Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Females: Please wear bra reduce pulling incision, avoid rubbing lower edge Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments Wound Check: [2164-5-8] 10:00 Surgeon: Dr. [Last Name (STitle) ] [2164-5-31] @ 1pm Cardiologist/PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) 1270] [Telephone/Fax (1) 1144] Date/Time:[2164-5-15] 10:30 Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Completed by:[2164-4-27]	[ "2724", "4019" ]
Admission Date: [2115-2-22] Discharge Date: [2115-3-19] Date Birth: [2078-8-9] Sex: Service: MEDICINE Allergies: Vicodin Attending:[First Name3 (LF) 4891] Chief Complaint: Post-cardiac arrest, asthma exacerbation Major Surgical Invasive Procedure: Intubation Removal chest tubes placed outside hospital R CVL placement History Present Illness: Mr. [Known lastname 3234] 36 year old gentleman PMH signifciant dilated cardiomyopathy s/p AICD, asthma, HTN admitted OSH dyspnea admitted MICU PEA arrest x2. patient initially presented LGH ED hypoxemic respiratory distress. OSH, received CTX, azithromycin, SC epinephrine, solumedrol. OSH, became confused subsequently episode PEA arrest intubated. received epinephrine, atropine, magnesium, bicarb. addition, bilateral needle thoracostomies report air return left, subsequently bilateral chest tubes placed. approximately 15-20 minutes rescucitation, ROSC. received vecuronium started epi gtt asthma cooling protocol, transferred [Hospital1 18] evaluation. note, patient admitted LGH [1-4] dyspnea, subsequently diagnosed CAP asthma treated CTX azithromycin. Per family, also multiple admissions winter asthma exacerbations. . [Hospital1 18] ED, 35.3 102 133/58 100%AC 500x20, 5, 1.0 ABG 7.16/66/162. CTH unremarkable. CTA chest, afterwhich went PEA arrest. Rescucitation last approximately 10-15 minutes multiple rounds epi bicarb, ROSC. admitted MICU management. . Currently, patient intubated, sedated, parlyzed. Past Medical History: Asthma Dilated cardiomyopathy Multiple admissions dyspnea winter ([1-26]). Anxiety/depression CKD HLD Obesity HTN Social History: Unknown Family History: Unknown Physical Exam: ADMISSION: VS: 35.9 124 129/67 99% AC 480x24, 5, 1.0 Gen: ETT place, intubated, sedated. HEENT: ETT place. CV: Tachy S1+S2 Pulm: Poor air movement bilaterally. Diffuse wheezes bilaterally. Abd: S/D hypoactive BS Ext: 1+ edema bilaterally Neuro: Unresponsive. . Discharge: 98.5 102/65 76 20 95-98% RA cage bed prevent patient falling bed. Occasionally calling out. Lungs clear without wheezes. Pertinent Results: Labs Admission: [2115-2-22] 08:50AM BLOOD WBC-19.5* RBC-4.76 Hgb-14.9 Hct-44.3 MCV-93 MCH-31.4 MCHC-33.7 RDW-12.9 Plt Ct-201 [2115-2-22] 08:50AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2* [2115-2-22] 08:50AM BLOOD Glucose-306* UreaN-21* Creat-1.2 Na-144 K-4.1 Cl-111* HCO3-28 AnGap-9 [2115-2-22] 08:50AM BLOOD Albumin-3.4* Calcium-6.2* Phos-5.5* Mg-2.2 [2115-2-22] 09:32AM BLOOD calTIBC-320 Ferritn-1129* TRF-246 [2115-2-22] 07:17AM BLOOD Type-ART pO2-162* pCO2-66* pH-7.16* calTCO2-25 Base XS--6 Intubat-INTUBATED . Labs Discharge [2115-3-18] 11:34AM BLOOD Type-ART pO2-95 pCO2-33* pH-7.54* calTCO2-29 Base XS-5 Intubat-NOT INTUBA [2115-3-5] 05:35AM BLOOD ALT-49* AST-23 AlkPhos-53 TotBili-0.9 [2115-3-19] 04:45AM BLOOD Glucose-73 UreaN-25* Creat-1.4* Na-133 K-4.1 Cl-95* HCO3-21* AnGap-21* [2115-3-19] 04:45AM BLOOD WBC-12.4* RBC-4.47* Hgb-14.3 Hct-41.3 MCV-93 MCH-32.0 MCHC-34.6 RDW-13.3 Plt Ct-352 [2115-3-19] 04:45AM BLOOD Neuts-56 Bands-0 Lymphs-38 Monos-3 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 . CXR (in MICU): Mr read - cardiomegaly, RIJ SVC, ETT 4.5 cm carina. Blunting costophrenic angles bilaterally low lung volumes. Loss retrocardiac diagphragm bilateral opacities (L>R) . CXR: 1. NG tube 7.2 cm carina. [Month (only) 116] consider advancing optimal placement. 2. Severe cardiomegaly globular shape. absence prior comparison, differential broad, including moderate pericardial effusion, mediastinal hemorrhage, acute cardiac failure. Recommend clinical correlation. . CTH: read, acute bleed . CTA Chest: 1. evidence pulmonary embolism, although evaluation subsegmental branches limited. 2. Moderate cardiomegaly without pericardial effusion. 3. Bilateral dependent atelectasis. 4. Multiple nondisplaced rib fractures right, subacute. Also possible subtle nondisplaced fractures left ribs. 5. Nondisplaced acute sternal fracture addition subacute nondisplaced sternal fracture. . TTE: left atrium moderately dilated. estimated right atrial pressure 10-20mmHg. Left ventricular wall thicknesses normal. left ventricular cavity severely dilated. LV systolic function appears depressed (ejection fraction ? 30 percent) regional variation. considerable beat-to-beat variability left ventricular ejection fraction due irregular rhythm/premature beats. right ventricular free wall thickness normal. right ventricular cavity dilated depressed free wall contractility. aortic root mildly dilated sinus level. ascending aorta mildly dilated. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets structurally normal. mitral valve prolapse. Mild (1+) mitral regurgitation seen. pulmonary artery systolic pressure could determined. pericardial effusion. . ECG (post-arrest): Sinus 1:1 conduction. LAA. LAD, RBBB, LAFB. STD V4-V6. . ECG (pre-arrest): Sinus 1:1 conduction. LAD, bifascicular block. lateral STD. . ECG (OSH, unclear pre/post arrest): Sinus 1:1 conduction. Bifascicular (RBBB, LAFB) block. STD V5-6. . EEG [2-27] IMPRESSION: abnormal video EEG telemetry due slow disorganized background 6.5 Hz bursts generalized slowing showed clear reactivity. findings indicate severe encephalopathy. may consistent patient's history anoxia; however, toxic/metabolic disturbances, infection, medication effects also among frequent causes encephalopathy. clear epileptiform discharges seizures seen. LUMBAR SPINE [2115-3-11] CLINICAL INFORMATION: Evidence fracture, seizure, fall, low back pain. FINDINGS: Three views lumbar spine demonstrate mild narrowing left femoroacetabular joint. mild scoliosis thoracolumbar spine. ventricular lead pacemaker identified. fracture L2 L5 identified. However, compression fracture L1, compression superior endplate, sclerotic fracture line. Given mechanism fall, acute pain referable L1, would considered acute finding. apparent retropulsion posterior margin L1 spinal canal. fractures identified time. Facet joints aligned. early calcification aorta. IMPRESSION: Compression fracture L1 anterior wedge deformity, likely acute finding. fractures identified. EKG: Normal sinus rhythm. Complete right bundle-branch block left anterior fascicular block. Diffuse ST-T wave changes laterally. CT Head: COMPARISON: [2115-2-22]. TECHNIQUE: Non-contrast axial images obtained brain. FINDINGS: intracranial hemorrhage, edema, loss [Doctor Last Name 352]/white matter differentiation. Ventricles sulci normal size configuration. basilar cisterns compressed. Paranasal sinuses demonstrate fluid sphenoid air cells right posterior ethmoid air cell, likely related prolonged hospitalization. Mastoid air cells well aerated. IMPRESSION: evidence acute intracranial abnormalities. Brief Hospital Course: Mr. [Known lastname 3234] 36 year old gentleman PMH signifciant dilated cardiomyopathy s/p AICD, PE anticoagulation, asthma, HTN admitted OSH dyspnea transferred [Hospital1 18] MICU PEA arrest x2. # PEA arrest subsequent anoxic brain injury.: Suspect original OSH PEA arrest due hypoxemia acidosis, [Hospital1 18] ED PEA arrest due acidosis admission pH 7.16 arrival. TTE evidence RV failure suggest PE. LVEF 30% known dilated cardiomyopathy. cooled per protocol. Initially, EEG concerning without evident brain activity. hospital day 3, comatose activity prognosis guarded. However, patient able weaned vent course next three days mental status improved. alert, oriented place day week moving 4 extremities. became interactive transfer floor, initially speaking spanish English always making sense started responding appropiately following commands. hospital day 11 witnessed grand mal seizure given ativan started Keppra neurology consult. mental status worse 24 hours seizure slowly returned recent baseline. somewhat aggitated Keppra switched Topiramate. subsequent seizure [3-18] LUE tonic clonic activity impaired consciousness resolved spontaneously 1-2 minutes. contineud topamax per neuro recommendations. OT PT consulted worked patient likely require long rehabilitation course. time discharge patient alert, oriented (though always date), following commands impulsive poor motor planning leading several falls. Neurology notes indicate patient potential toimprove neurologic standpoint. also may recurrent seizures treated ativan IV IM neccessarily indicate patient needs return hospital unless continue greater 5 minutes multiple recurrent seizures complications aspiration. -patient Topiramate 25mg PO BID [3-22] PM increase 50mg po BID seven days increase 75mg [Hospital1 ] ongoing. -patient follow Dr. [Last Name (STitle) ] [Name (STitle) ] s/p arrest neurology clinic -patient require intensive PT OT anoxic brain injury unit. . # Respiratory failure: Believed due status asthmaticus, although inciting event unclear. [Name2 (NI) 227] multiple cardiac arrests, also concern development ARDS. patient initially treated broadly vancomycin, cefepime, flagyl, cipro, oseltamavir. treated IV soludemedrol albuterol MDI. ventialted according ARDS-Net protocol. admission, two chest tubes placed pneumothoraces. removed hospital day 1. first several days, respiratory status comprimised lobar collapse, first RUL RML. extubation initially limited agitation requiring sedation requirements high PEEP maintain oxygenation. oxygenation improved diuresis agitation better controlled seroquel. extubated [3-1] respiratory status stable. Asthma treated standing PRN albuterol ipratriopium slow prednisone taper l completed [2115-3-18] restarted Advair -patient may require additional nebs top standing advair though respiratory status stable, without wheezing last week. - would like benefit outpatient PFTs scheduled see pulmonologist follow up. . # Ventilator associated pneumonia: Patient developed fever [2-27] new infiltrates chest xray intubated. initially covered vanc/cefepime cipro. Cipro eventually discontinued. grow organisms yeast sputum. completed 8 day course Vanco/Cefepime. . # Myoclonus: mental status improved, noted myoclonic jerks. per neurology, likely [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] Syndrome anoxic injury purkinje cells. jerks continued one week became rare. . # dilated [Last Name (LF) 89982], [First Name3 (LF) ] 30%. s/p ICD. Patient diuresed IV lasix ED transitioned PO lasix, home dose, floor. respiratory status remained stable. Also continued home dose carvedilol Lisinopril ACE downtitrated 40 20 elevated Cr 1.9 [3-18] slightly low BPs high 90s/60s. BP improved 100s/60s. . #Hypertension: Patient's home regimen continued floor, SBP dipped high 80s low 90s lisinopril decreased 20mg po daily SBP remained 100-130. . # L1 compression fracture: patient fell, complaining low back pain L-spine Xray performed showed L1 compressin fracture cord impingement imaging. patient localizing deficits serial neuro exam. treated pain medication including low dose ultram, standing tylenol lidocaine patch. Calcitonin tried pain compression fracture seem help symptoms discontinued. . # Leukocytosis: WBC >20 persistently MICU even treated infection. Since new infection found presumed [12-26] steroids leukocytosis improved prednisone taper. WBC 12 day discharge . # Hyperglycemia: Patient known diabetic felt [12-26] steroids, sugars controlled sliding scale insulin hospital longer insulin requirements prednisone tapered. . #. [Last Name (un) ]: Cr 1.9 [3-18] 1.2 improved 1.4 [3-19] decreasing ACE 500cc bolus. repeat creatinine labs [3-22] ensure stability. # Guardianship: Guardianship paperwork started hospital. Medications Admission: Carvedilol 25 [Hospital1 ] Lasix 80 mg po bid Xanax 0.25 mg 1-2 tabs prn albuterol MDI Ibuprofen prn Benadryl prn Advair diskus Lsinopril 40 daily Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed Constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed pain/fever. 4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [11-25] Tablet, Rapid Dissolves PO QHS (once day (at bedtime)) needed sleep. 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times day) needed pain/fever. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours 12 hours every 24 hour period. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) neb Inhalation every six (6) hours. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) needed SOB. 16. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 3 days: 1 [Hospital1 ] [3-22] PM increase 2 tablets [Hospital1 ] 7 days 3 tablets [Hospital1 ] ongoing. 17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed back pain. 18. fluticasone-salmeterol 250-50 mcg/dose Disk Device Sig: One (1) inh Inhalation [Hospital1 ] (2 times day). 19. lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection twice day needed seizure last longer 5 minutes. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Anoxic Brain Injury s/p PEA arrest x2 Status Asthmaticus Ventilator Associated Pneumonia Chronic Systolic Heart Failure L1 compression fracture Seizures hypoxic brain injury Discharge Condition: Mental Status: Confused - sometimes. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane) poor motor planning Discharge Instructions: came hospital cardiac arrest asthma exacerbation. another cardiac arrest hospital admitted MICU. required intubation able wean machine breathe own. treated pneumonia asthma. mental status slowly improved, though 2 seizures, last [3-18]. started ons eizure medications this. . Please take medications prescribed follow doctors [Name5 (PTitle) 7928]. Followup Instructions: Department: PULMONARY FUNCTION LAB When: WEDNESDAY [2115-4-3] 1:10 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [2115-4-3] 1:30 PM With: DR [Last Name (STitle) ]/DR [Last Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [2115-4-11] 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage	[ "5849", "4280" ]
Admission Date: [2187-7-13] Discharge Date: [2187-7-23] Date Birth: [2104-8-30] Sex: F Service: CARDIOTHORACIC Allergies: Penicillin V / Methyldopa Attending:[First Name3 (LF) 165] Chief Complaint: general malaise Major Surgical Invasive Procedure: dental extractions [2187-7-15] redo sternotomy/AVR (#19 CE Magna)-[2187-7-17] History Present Illness: 82 yo F s/p CABG [2177] severe recent NSTEMI, preop [Hospital 1291] transferred [Hospital3 ] SOB, recurrent pulmonary edema. Past Medical History: Right carotid endarterectomy CABG [Hospital6 ] [2181] (LIMA LAD, SVG RCA, SVG first diagonal, SVG OM2) NSTEMI [2187-5-1] Renal insufficiency (baseline creatinine 1.5) Hypertension Severe Aortic stenosis Dementia Peripheral Vascular Disease Anemia (baseline hematocrit 32-34) Social History: Social history significant absence current tobacco use. history alcohol abuse. Family History: mother died heart attack age 61. dad died CVA age 47. sister diabetes. son passed away. six miscarriages. Physical Exam: HR 64 RR 20 BP 129/44 NAD Lungs scattered rales Heart RRR 3/6 SEM radiating neck Extrem warm 62" 72 kg Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. TEE related complications. Resting bradycardia patient. See Conclusions post-bypass data post-bypass study performed patient receiving vasoactive infusions (see Conclusions listing medications). Conclusions PRE-BYPASS: 1. left atrium dilated. Mild spontaneous echo contrast seen body left atrium. left atrial appendage thrombus cannot excluded. atrial septal defect patent foramen ovale seen 2D, color Doppler saline contrast maneuvers. 2. mild symmetric left ventricular hypertrophy. left ventricular cavity size normal. Overall left ventricular systolic function low normal (LVEF 50-55%). 3. Right ventricular chamber size free wall motion normal. 4. simple atheroma ascending aorta. complex (>4mm) atheroma aortic arch. complex (>4mm) atheroma descending thoracic aorta. 5. three aortic valve leaflets. aortic valve leaflets severely thickened/deformed. severe aortic valve stenosis (area 0.5 cm2). aortic regurgitation seen. 6. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. 7. small left pleural effusion. Dr. [Last Name (STitle) ] notified person results OR. POST-BYPASS: post-bypass study, patient receiving vasoactive infusions including phenylephrine AV paced. 1. well-seated bioprosthetic valve seen mitral position normal leaflet motion gradients (mean gradient = 11 mmHg cardiac output 2.6 L/min). Trivial central aortic regurgitation seen. 2. Regional global left ventricular systolic function normal. 3. Right ventricular systolic function post-bypass moderately hypokinetic. 4. intra-atrial septum dynamic. 5. Aortic contours intact post-decannulation. [Known lastname ],[Known firstname 24357] L [Medical Record Number 41597] F 82 [2104-8-30] Radiology Report CHEST (PORTABLE AP) Study Date [2187-7-19] 2:14 PM [Last Name (LF) ],[First Name3 (LF) ] CSURG CSRU [2187-7-19] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 41598] Reason: ? ptx s/p ct removal [Hospital 93] MEDICAL CONDITION: 82 year old woman s/p cabg REASON EXAMINATION: ? ptx s/p ct removal Final Report STUDY: Single portable AP chest radiograph. INDICATION: 82-year-old female status post CABG chest tube removal. COMPARISON: [2187-7-18]. FINDINGS: Patient extubated removal right basilar chest tube Swan-Ganz catheter/NG tube. Atelectasis left lower lobe improved. Small left pleural effusion remains. upper lungs remain clear. Bilateral subclavian artery calcifications noted. Median sternotomy wires remain stable condition. IMPRESSION: 1. Interval removal multiple lines tubes without pneumothorax. 2. Improvement left lower lobe atelectasis. 3. Residual small left pleural effusion. study report reviewed staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name 4391] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: [Doctor First Name ] [2187-7-19] 4:49 PM Imaging Lab Brief Hospital Course: admitted cardiac surgery. Dental consult called tooth extractions recommended. [7-15] 5 teeth extracted. [7-17] taken operating room [7-17] underwent redo sternotomy AVR. transferred ICU stable condition. extubated POD #1. Chest tubes removed transferred floor POD #2 begin increasing activity level. gently diuresed toward preop weight. Beta blockade titrated. Pacing wires removed POD #3.She several episodes fib coumadin started. Target INR 2.0-2.5. continued make good progress cleared discharge rehab POD #6. Pt. make followup appts. per discharge instructions. Medications Admission: ASA 325, lopressor 25", lipitor 10, lovenox 40, norvasc 5, diovan 160,acidophilus [Hospital1 ] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours needed pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times day). 9. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) units SC Subcutaneous day. 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO (Once) 1 doses: 3 mg today [7-23]; dosing per rehab provider;target INR 2.0-2.5. 11. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO BID (2 times day): hold K >4.8.[Month (only) 116] DC lasix stopped. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: s/p AVR R CEA, CABG [Hospital6 ] [2181] (LIMA LAD, SVG RCA, SVG first diagonal, SVG OM2), NSTEMI [Month (only) 547] [2187], Renal insufficiency (baseline creatinine 1.5), Hypertension, Severe AS, dementia, PVD, Anemia (baseline hematocrit 32-34) ;postop Fib Discharge Condition: Stable. Discharge Instructions: Call fever, redness drainage incision weight gain 2 pounds one day five one week. Shower, baths, lotions, creams powders incisions. lifting 10 pounds. driving follow surgeon least one month. Followup Instructions: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10543] 2 weeks Dr. [First Name (STitle) ] 4 weeks [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2187-7-23]	[ "4280" ]
Admission Date: [2183-3-23] Discharge Date: [2183-5-9] Date Birth: [2124-10-29] Sex: Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7591] Chief Complaint: Weakness Major Surgical Invasive Procedure: Bone marrow biopsy History Present Illness: 58 y/o presented [Hospital1 ] [Location (un) 620] syncopal episode today sustained facial hematoma. Pt remembers going bathroom early morning awoke floor approx 2hrs laterwith left sided facial bruising incontinence. Pt reports severe nosebleeds began 2 days prior admission. saturday, feeling lightheaded developped severe right thigh pain. Sunday, noticed decreased appetite, left thigh pain fevers/chills. review symptoms, pt noticing increased bruising general lethargy last week. Per report, wife trying get see [Name8 (MD) ] MD months concerned generalized weakness. . Pt initially presented [Hospital1 ] [Location (un) ] febrile 101.2 received Vanc Ceftazidime neutropenic fever. underwent head CT revealed small foci petechial hemorrhage within left frontal lobe small subarachnoid hemorrhage. Initial VS arrival [Hospital1 18] ED: 100.4 P 76 BP 110/55 R 18 O2 sat 99% RA. Pt given Acyclovir possible Zoster. underwent CTA negative PE received 2L NS IVF. Pt transfused second bag plts prior arrival ICU. . arrival, pt complaining right & left proximal thigh pain approx [8-22]. Otherwise, denying CP, SOB, HA, abd pain, nausea, visual changes. feeling exhausted still mildly lightheaded. Past Medical History: Osteoarthritis (knees) Social History: Pt works headmaster [Initials (NamePattern4) ] [Last Name (NamePattern4) 1573] school. lives wife two healthy children, three grandchildren. used marathon runner. Denies smoking illicit drug use. reports consuming approx 1 drink per day. Family History: Father died metastatic prostate cancer 80s, mother alive HTN insulin resistance. Physical Exam: Vitals: T: 98.6 BP: 137/73 P: 83 R: 20 O2: 975 RA General: alert, oriented, large ecchymosis left orbit, eye swollen shut HEENT: sclera anicteric, dry MM, oropharynx dried blood Neck: supple, JVP elevated, precervical lymphadenopathy Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: RRR, normal S1/S2, m/r/g Abdomen: soft, NT, ND, NABS, rebound tenderness guarding, appreciable hepatosplenomegaly Inguinal: inguinal lymphadenopathy Ext: Warm, well perfused, 2+ pulses Neuro: CN 2-12 intact (except unable assess left eye due swelling & eccyhmoses). Strength 5/5 four extremities distally. Unable assess proximal muscle strength lower extremities [3-17] pain. Sensation intact distally. Gait assessed. saddle anesthesia, focal spinal tenderness. Pertinent Results: [2183-3-23] 08:46PM GLUCOSE-116* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [2183-3-23] 08:46PM ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-286* CK(CPK)-126 ALK PHOS-65 TOT BILI-0.8 [2183-3-23] 08:46PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.0 URIC ACID-5.1 [2183-3-23] 08:46PM WBC-0.7* RBC-2.21* HGB-7.6* HCT-20.3* MCV-92 MCH-34.5* MCHC-37.5* RDW-17.5* [2183-3-23] 08:46PM I-HOS-AVAILABLE [2183-3-23] 08:46PM PLT COUNT-43* [2183-3-23] 08:46PM PT-17.0* PTT-29.8 INR(PT)-1.5* [2183-3-23] 08:46PM FDP-160-320* [2183-3-23] 08:46PM FIBRINOGE-303 [2183-3-23] 08:46PM GRAN CT-230* [2183-3-23] 06:55PM PLT COUNT-53# [2183-3-23] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]->1.050 [2183-3-23] 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2183-3-23] 03:40PM URINE RBC-[4-17] WBC-[4-17] BACTERIA-RARE YEAST-NONE EPI-0-2 [2183-3-23] 03:40PM URINE MUCOUS-OCC [2183-3-23] 03:16PM LACTATE-2.0 [2183-3-23] 03:10PM GLUCOSE-123* UREA N-16 CREAT-0.9 SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15 [2183-3-23] 03:10PM estGFR-Using [2183-3-23] 03:10PM CK(CPK)-147 [2183-3-23] 03:10PM CK-MB-1 cTropnT-<0.01 [2183-3-23] 03:10PM WBC-0.7* RBC-2.63* HGB-8.9* HCT-24.2* MCV-92 MCH-34.0* MCHC-37.0* RDW-17.8* [2183-3-23] 03:10PM NEUTS-8* BANDS-4 LYMPHS-76* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2* OTHER-6* [2183-3-23] 03:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [2183-3-23] 03:10PM PLT SMR-VERY LOW PLT COUNT-29* [2183-3-23] 03:10PM PT-15.9* PTT-28.2 INR(PT)-1.4* [2183-3-23] 03:10PM GRAN CT-290* [2183-3-24] CT HEAD IMPRESSION: 1. Increased size left frontal right posterior cingulate gyrus intraparenchymal hemorrhages. 2. Increased size right frontal, right temporal, interhemispheric subarachnoid hemorrhage. 3. midline shift. evidence acute infarction. [2183-3-24] MRI L/T-SPINE evidence acute spine injury within cervical, thoracic lumbar spine. Note made fluid level within lower lumbar spine, consistent layering subarachnoid blood. Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 40120],[Known firstname ] [2124-10-29] 58 Male [Numeric Identifier 40121] [Numeric Identifier 40122] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ]. MARIAPPAN SPECIMEN SUBMITTED: Immunophenotyping, Bone Marrow Procedure date Tissue received Report Date Diagnosed [2183-3-24] [2183-3-24] [2183-3-25] DR. [Last Name (STitle) ]. MARIAPPAN/ttl Previous biopsies: [Numeric Identifier 40123] BONE MARROW BIOPSY (1 JAR). INTERPRETATION Immunophenotypic findings consistent involvement by: immature population cells consistent acute myelogenous leukemia. Lack CD34 HLA-DR [Last Name (STitle) 40124] consistent diagnosis acute promyelocytic leukemia. Correlation morphologic cytogenetic findings recommended. Brief Hospital Course: 58 y/o presenting syncopal episode found multiple small ICH new pancytopenia. complicated course AMPL treatment # Leukemia: Patient found AMPL via bone marrow biopsy day admission MICU. started ATRA monitored closely symptoms DIC, TLS ATRA syndrome. transfused needed PRBC, platlets FFP. develop overt signs DIC. induced Ara-c daunurubicin. counts responded appropriatly. repeat BM biopsy showed remission continue ATRA follow Dr. [Last Name (STitle) 410] plans stage two treatment. . # Fevers: initially Vancomycin cefepime first starting treatment due hx fevers home, culture data negative remained afebrile antibiotics discontinued. remained afebrile [4-14] spiked fever. cultured blood grew strep viridans. started vanco/cefepime time. also headache day spiked CT done showing appeared brain abscesses. antibiotics eventually broadened vanco, meropenem, fluconzaole flagyl brain abscesses. continued spike, though approximately week. complained thigh pain ultrasound showing bilateral fluid collections. drained IR grew MSSA. developed pneumonia febrile period transferred ICU several days. required O2 discharged ICU. ICU, neutrophil count started drop, worried might drug effect. vanco discontinued counts began recover. Eventually meropenem, voriconazole acyclovir stopped fevers. repeat CT scan showed resolution PNA. Serial repeat head CTs showed slow decrease size abscesses. MRI thigh showed retained small fluid collections bilaterally. plan complete 6 week course antibiotics brain abscesses. reimage thighs MRI outpatient depending results, either need surgical drainage still prolonged course abx. follow ID. . # ICH: Pt multiple small ICH sustained fall acute left sided head injury setting profound thrombocytopenia. CT head revealed small foci intraparenchymal hemorrhage subarachnoid hemorrhage. (no hydrocephalus shift). [3-24] follow-up Head CT revealed interval increase hemorrhage without appreciable midline shift infarction. pt's neurologic exam remained stable. Neurosurgery followed closely. Platlet goal > 75K. repeat head CT one month fall showed brain abscesses discussed above. Neuro onc consulted followed along. decided biopsy. also required heparin lovenox DVTs, repeat head CTs anticoaulants remained stable without new bleeds. . # Thigh pain/weakness: Etiology unclear unable get good exam limited pain. may bone marrow pain. evidence hematoma cellulitis. bowel bladder dysfunction, saddle anesthesia, focal spinal tenderness indicate acute cord compression. MRI T/L-spine revealed evidence acute cord compression. evidence layering fluid likely SAH. Although unlikely causing pt's leg pain (nerve irritation secondary blood) Neurosurgery recommended starting Decadron [2182-3-24]. kept decadron chemotherapy initiated. Eventually found abscesses thighs, discussed above. . # Afib - pt went afib ICU. blood pressures remained stable started metoprolol. high rates 130s-140s; contined afib week remained NSR week prior discharge. metoprolol titrated 25 mg tid good rate control. . # [Name (NI) 6059] - pt one episode 16 b [Name (NI) 6059] v. afib aberrancy. Cards consulted agressive electrolyte repletion continued metoprolol. occurrences. . # Vasovagal bradycardia - day prior admission, patient bowel movement, noted telemetry brady 30s, felt light headed resolved 5 minutes. Appeared vaso-vagal occurrences. Again, cards consulted recommended leaving metoprolol dose 25 mg tid, bb actually helps prevent vagal episodes. . # DVTs - patient ICU, developed bilaterally pedal edema, thought initially due large amount IVFs. new afib, though, ultrasounds found DVTs R leg, R arm (because edematous pain around new PICC line). Heparin started overnight, hx ICHs, decided stop heparin place IVC filter. put place without complications. Evenutally found bilaterally leg DVTs bilateral upper extremity DVTs. point, decided anticoagulated. Heparin initially. Repeat head CT showed bleed. converted lovenox outpatient treatment DVTs. also VQ scan findings DVT showed low prob PE. . # Access - pt initially subclavian line, pulled patient febrile early [Month (only) 958]. PIVs transfer ICU PICC line placed. PICC line removed DVT found arm. PIVs IR guided subclavian line placed. outpatient continuation 6 week course antibiotics, hickman placed PICCs could placed due bilateraly UE DVTs. . # Pt discharged walking around, passing PT going stairs. respiratory status much improved O2 SOB. advised start work yet take easy, although, ready get back work soon possible. Medications Admission: None Discharge Medications: 1. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous 6x/day. Disp:180 flushes Refills:2 2. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection 10x/day. Disp:300 flushes Refills:2 3. Meropenem 1 gram Recon Soln Sig: One (1) recon soln Intravenous every eight (8) hours 22 days: make end date [5-30]; total 6 week course. Disp:66 recon soln Refills:0 4. Vesanoid 10 mg Capsule Sig: Five (5) Capsule PO twice day 14 days: substitutions please. Disp:140 Capsule(s) Refills:0 5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:180 Capsule(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 7. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). Disp:90 Tablet(s) Refills:2 8. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:60 syringe Refills:2 Discharge Disposition: Home Service Facility: Critical Care Systems Discharge Diagnosis: APML Intracranial hemorrhage Syncope Discharge Condition: vital signs stable, walking around, lovenox, normal neurological exam, afebrile Discharge Instructions: admitted hospital fell. found low blood counts bone marrow biospy showed leukemia. also small areas bleeding head stable based repeat CT scans. received chemotherapy leukemia. . here, developed infection brain around areas inital bleeds found, well thighs. treated antibiotics need continue going home. . also developed blood clots arms legs. place filter inferior vena cave (a large vein abdomen) clots would go lungs. also anticoagulated heparin. go home lovenox stay anticoagulated. . Lastly, developed heart arrhythmia called atrial fibrillation. that, continue taking medicine metoprolol. . home nurse help wife antibiotics lovenox shots. make sure start returning work slowly. probably best work work home first week see feeling starting think going back school. discuss progress Dr. [Last Name (STitle) 410] follow appointments. . return hospital fainting, headaches, dizziness, chest pain, shortness breath, swelling extremities, palpitiations concerns. Followup Instructions: Please follow Dr. [Last Name (STitle) 410] [Hospital Ward Name 23] 7 Tuesday [2183-5-13] 1:30 pm. Phone number [Telephone/Fax (1) 3241]. Please follow infectious disease Dr. [Last Name (STitle) ] [2183-5-19] 3:00 pm. Phone number ([Telephone/Fax (1) 4170]. need repeat MRI prior seeing Dr. [Last Name (STitle) ]. give date time next appointment. Completed by:[2183-5-15]	[ "5849", "486", "4019", "2859" ]
Admission Date: [2127-7-11] Discharge Date: [2127-7-13] Date Birth: [2070-1-18] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 425] Chief Complaint: dizziness,nausea,vomiting Major Surgical Invasive Procedure: none History Present Illness: HPI: 57 y/o Spanish speaking female h/o HTN, DM 2, hyperlipidemia, CAD s/p 4V CABG [4-12], asthma presented PCP regularly scheduled visit, complained dizziness, nausea, vomiting one week, chest pain, found hypotensive. sent ED PCP. [Name10 (NameIs) ] ED got atropine x 3 bradycardia, lasix, glucagon blood sugar 30s, started dopamine drip hypotension, weaned CCU without futher hypotension. Ruled MI. AST/ALT amylase/lipase normal. RUQ US done last month [State 108] reportedly normal. . decribes vomiting one week going doctor's visit. vomiting almost daily one week. dizzy week, getting worse going sitting standing. Described room spinning lightheadedness. syncope falls. chest pain lasted one minute occured vomiting. mild cough week, sputum mild fevers. . . Past Medical History: HTN Hyperlipidemia DM 2 CAD s/p 4V CABG ([4-12]) LIMA LAD, SVGs anterior obtuse marginal, posterior obtuse marginal, RCA. Obesity Asthma s/p CCY s/p C-section s/p Left foot surgery Social History: Married. Formerly [Male First Name (un) 1056], Spanish-speaking only. history tobacco use, EtOH, IVDU. Family History: Mother CAD, CVA, DM2. Father died complications renal failure. Extensive DM family. Physical Exam: Vitals: 98.6 BP 120/70 HR 69 RR 18 SAT 96% RA General: NAD HEENT: NC, AT, amicteric, injections, PERRLA, EOMI, OP clear. Neck: JVP elevation. wound right neck tender palpation, purulent drainage, erythema. CV: Normal S1, S2 m/r/g. Pulm: Minimal bibasilar crackles. wheezes. Abd: Soft, NT, ND, + BS. Ext: c/c/e. DP 2+ B/L. Evidence venous stasis changes. Healing left thigh wound packed dressing covered gauze. drainage erythema. Pertinent Results: Labs discharge: BUN 35 Cr 1.3 CK 69 trop <0.01 WBC 10.1 HCT 31.8 . EKG: NSR 60, normal axis, acute ST changes . Last CXR lungs clear . [2127-7-11] 03:07PM BLOOD WBC-9.7 RBC-3.03* Hgb-8.8* Hct-25.7* MCV-85 MCH-29.0 MCHC-34.1 RDW-15.3 Plt Ct-445* [2127-7-13] 06:45AM BLOOD WBC-10.1 RBC-3.77* Hgb-10.9* Hct-31.8* MCV-84 MCH-28.8 MCHC-34.2 RDW-15.4 Plt Ct-385 [2127-7-11] 03:07PM BLOOD Neuts-56.2 Lymphs-36.5 Monos-4.4 Eos-2.6 Baso-0.2 [2127-7-11] 06:19PM BLOOD Neuts-78.2* Lymphs-17.2* Monos-3.2 Eos-1.3 Baso-0.2 [2127-7-11] 03:07PM BLOOD Plt Ct-445* [2127-7-13] 06:45AM BLOOD Glucose-119* UreaN-35* Creat-1.3* Na-140 K-5.1 Cl-104 HCO3-24 AnGap-17 [2127-7-11] 08:25PM BLOOD ALT-18 AST-16 CK(CPK)-49 AlkPhos-89 Amylase-79 TotBili-0.1 [2127-7-11] 08:25PM BLOOD Lipase-61* [2127-7-11] 03:07PM BLOOD cTropnT-<0.01 [2127-7-11] 08:25PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2127-7-12] 06:22AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2127-7-11] 08:25PM BLOOD calTIBC-324 Ferritn-265* TRF-249 [2127-7-11] 06:29PM BLOOD Lactate-0.8 [2127-7-11] 03:07PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2127-7-11] 03:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . bcx [7-11]: growth ucx [7-11]: genital contamination Brief Hospital Course: A/P: 57 y/o Spanish speaking female h/o HTN, DM2, CAD s/p 4VCABG, hyperlipidemia, asthma presented ED hypotension, resolved, brief episode chest pain, ruled out, abdominal pain, likely Gas/GERD. . 1. Hypotension: patient nausea vomiting prior admission found hypotensive PCP's office. actually given lasix initially started dopamine gtt. unclear note got fluid. hypotension probably due dehydration vomiting week prior admission. Dopamine gtt weaned patient issues hypotension. discharged lisinopril atenolol. Lasix dose decreased 20 mg QD KCl d/c'd halved lasix K discharge 5.1. . 2. Renal Failure: Patient came creatinine 1.6 baseline unknown. Could chronic renal failure DM giving chronic renal insufficiency perhaps also prerenal vomiting prior admission. Creatinine steadily improved 1.3 discharge. . 3. Anemia: Crit admission 25. Likely ACD DM. s/p transfusion 2 units CCU. HCT improving. Crit 31.8. . 4. DM2:bedtime sugar 152, fasting 73 noon 118. continued actos avandia well RISS patient advised take home doses lantus regular insulin home. . 5. HTN: Blood pressure stable dopamine gtt titrated CCU. issues hypertension hypotension. Discharged patient atenolol lisinopril. . 6. CAD: Patient denies chest pain. Lipid profile showed LDL 84, HDL 54. continued ASA, atenolol, lisinopril. acute issues. . 7. Asthma: wheezing, stable sats. gave patient albuterol PRN. . Medications Admission: Lisinopril 20 mg PO daily Lasix 40 mg PO daily Trazodone Avandia 2 mg PO daily Lantus 100 QD Regular insulin 20 am, 30 pm Protonix 40 mg PO daily Zoloft Albuterol KCl 10 meq PO daily Atenolol 25 mg PO daily ASA 81 mg PO daily Lipitor 10 mg PO daily Actos 45 mg PO daily Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Trazodone 50 mg Tablet Sig: .5 Tablet PO bedtime needed insomnia. Disp:15 Tablet(s) Refills:0 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Hypotension [1-9] volume depletion vomiting Discharge Condition: Patient afebrile, hemodynamically stable tolerating BP meds. Discharge Instructions: Please take medications directed. Please follow-up outpatient appointments. Please return ED develop dizziness, loss consciousness, chest pain, trouble breathing, vomiting, difficulty urinating concerning symptoms. Followup Instructions: Please follow-up primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 23903] week. number [Telephone/Fax (1) 17826]. time, check right upper quadrant ultrasound. Patient also needs chem-7 checked lasix, lisinopril. put patient reduced dose lasix (20 mg QD) hypotension took KCl. see PCP week see really needs lasix 40 mg QD KCl.	[ "5849", "4019", "2859", "2720" ]
Admission Date: [2174-4-18] Discharge Date: [2174-5-17] Date Birth: [2135-11-15] Sex: F Service: MEDICINE Allergies: Prochlorperazine / Heparin Agents Attending:[First Name3 (LF) 3918] Chief Complaint: Abdominal Pain Major Surgical Invasive Procedure: Upper GI series small bowel follow Right heart catheterization IR guided paracentesis History Present Illness: 38 yo F w/ h/o remission s/p cord transplant [1-13], anthracycline-induced cardiomyopathy (EF 15-20% [1-14]) recurrent nausea vomiting presents abdominal pain, N/V x1 week note, pt admitted [Date range (1) ] nausea vomitting unclear etiology. discharged, tolerating good PO planned f/u neuro ? abdominal migraine GI possible contributing factors including food sensitivities gastroparesis. ED, VS: 98.8 94 138/100 16 100% [10-15] pain. CT A/P showed small umbilical hernia; interval increase size mild fat stranding interval increase ascites compared recent prior imaging. WBC 12.4 left shift, bili 2.1 1.1, Cr 2.7 2.3. Surgery consulted give CT finding feel indication surgery. received iv zofran morphine 4mg iv 1L IVF. arrival floor, patient reports [11-14] total body pain nausea. ice chips today threw ED. Review Systems: (+) Per HPI (-) Review Systems: Denies fevers, chest pain, SOB, diarrhea, constipation, dysuria, HA, change vision dizziness. Past Medical History: ONCOLOGIC HISTORY: ALL: - initially presented [2172-8-5] right chest right upper extremity pain paresthesias visual blurriness. WBC 149,000; received leukapheresis, started hydroxyurea. Dx'ed precursor B-cell ALL. - underwent phase induction daunorubicin, vincristine, dexamethasone, L-asparaginase, MTX; phase II cyclophosphamide, cytarabine, mercaptopurine, MTX - Bone Marrow Aspirate/Biopsy [2172-10-26] showed morphologic evidence residual leukemia - underwent allo double cord blood SCT [2173-1-11], course complicated neutropenic fever acute skin GVHD MEDICAL HISTORY: - Embolic stroke [3-/2174] coumadin - Cardiomyopathy due early anthracycline-related cardiotoxicity [10/2172] - Chronic kidney disease stage III/IV, baseline creatinine ~2.0-2.2 - Asthma - HTN - Cervical Intraepithelial neoplasia - C-section [2165] Social History: Smoke: never EtOH: Occasional past, none currently Drugs: Never Lives/works: Single, two children (ages 7 18). Lives [Location 686]. previously employed [Company 59330], working since diagnosed [2172-8-5]. Family History: Mother gastric cancer, passed age 40 Father HTN. Physical Exam: VS: 98 145/76 87 15 100% RA GEN: well appearing F NAD HEENT: slight dry MM, sclera anicteric, PERRL Cards: RR S1/S2 normal. prominent S3 Pulm: CTAB Abd: Hyperactive BS. Initially soft palpating stethoscope 4 quadrants suddenly exquisitely tender right. guarding initially. Unable assess HSM. Extremities: wwp, edema. PTs 2+. Neuro: CNs II-XII grossly intact. normal gait Psych: overly dramatic affect Pertinent Results: admission: [2174-4-18] 02:00PM BLOOD WBC-12.4* RBC-3.78* Hgb-11.4* Hct-36.3 MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* Plt Ct-212 [2174-4-18] 02:00PM BLOOD Neuts-67.3 Lymphs-23.8 Monos-7.7 Eos-0.5 Baso-0.7 [2174-4-18] 04:30PM BLOOD PT-30.1* PTT-29.4 INR(PT)-3.0* [2174-4-18] 02:00PM BLOOD UreaN-30* Creat-2.7* Na-142 K-4.8 Cl-99 HCO3-31 AnGap-17 [2174-4-18] 02:00PM BLOOD ALT-15 AST-18 AlkPhos-127* TotBili-2.1* [2174-4-18] 02:00PM BLOOD Lipase-63* [2174-4-18] 02:00PM BLOOD cTropnT-<0.01 [2174-4-18] 02:00PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.8* Mg-2.0 discharge: [2174-5-17] 12:00AM BLOOD WBC-19.1* RBC-3.86* Hgb-11.3* Hct-37.7 MCV-98 MCH-29.3 MCHC-30.0* RDW-17.8* Plt Ct-419 [2174-5-17] 12:00AM BLOOD Neuts-81.3* Lymphs-11.4* Monos-6.9 Eos-0.1 Baso-0.3 [2174-5-17] 12:00AM BLOOD PT-31.2* PTT-28.6 INR(PT)-3.1* [2174-5-17] 12:00AM BLOOD Fibrino-162 [2174-5-17] 12:00AM BLOOD Glucose-152* UreaN-78* Creat-2.9* Na-137 K-4.7 Cl-95* HCO3-31 AnGap-16 [2174-5-17] 12:00AM BLOOD ALT-51* AST-41* LD(LDH)-327* AlkPhos-107* TotBili-0.7 [2174-5-13] 12:11PM BLOOD cTropnT-<0.01 [2174-5-17] 12:00AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.1* Mg-2.7* UricAcd-8.7* [2174-4-27] 02:51AM BLOOD calTIBC-246* Ferritn-107 TRF-189* [2174-5-2] 05:55AM BLOOD [Doctor First Name ]-NEGATIVE dsDNA-NEGATIVE [2174-4-28] HHV-8 DNA, QL PCR Detected [2174-4-27] QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE [2174-4-29] ACE, SERUM 30 [10/2130] U/L Micro: [2174-4-25] 1:07 pm PERITONEAL FLUID GRAM STAIN (Final [2174-4-25]): POLYMORPHONUCLEAR LEUKOCYTES SEEN. MICROORGANISMS SEEN. FLUID CULTURE (Final [2174-4-28]): GROWTH. ANAEROBIC CULTURE (Final [2174-5-1]): GROWTH. ACID FAST CULTURE (Preliminary): MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [2174-4-30]): ACID FAST BACILLI SEEN DIRECT SMEAR. FUNGAL CULTURE (Final [2174-5-13]): FUNGUS ISOLATED. [2174-4-29] 10:15 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): MYCOBACTERIA ISOLATED. CMV Viral Load (Final [2174-5-6]): CMV DNA detected. ECG [2174-4-18]: Sinus rhythm. Possible left atrial abnormality. Lateral ST-T wave abnormality. Cannot rule myocardial ischemia. Poor R wave progression. Cannot rule anterior wall myocardial infarction indeterminate age. Compared previous tracing [2174-4-2] multiple described abnormalities persist. CT abdomen/pelvis without contrast [2174-4-18]: FINDINGS: small-to-moderate right pleural effusion, smaller size compared last CT torso. small pericardial effusion. Study suboptimal evaluation solid organs due lack IV contrast. limitation mind, extra- intra-hepatic biliary duct dilatation. Previously described presumably focal nodular hyperplasia segment VI liver clearly visualized non-contrast CT. presumably gallbladder wall edema third spacing moderate amount ascites. likely gallbladder sludge. Pancreas bilateral adrenal glands within normal limits considering limitation contrast administration. interval increase size fat-containing umbilical hernia measuring 2 cm transverse dimension mild fat stranding(2:50), correlate point tenderness/physical exam. appendix dilated (2:49), contains air likely small appendicolith (2:53). bowel obstruction. evidence colonic wall thickening, although evaluation suboptimal given lack IV PO contrast adjacent ascites.. kidneys normal size. evidence hydronephrosis. Due lack oral contrast, evaluation mesenteric lymph nodes suboptimal. scattered lymph nodes retroperitoneum, however, meet CT criteria pathologic enlargement. CT PELVIS: free fluid pelvis - ascites. uterus urinary bladder appear normal. rectum sigmoid scattered diverticula; however, evidence diverticulitis. OSSEOUS STRUCTURES: suspicious lytic sclerotic lesion. soft tissue stranding suggesting anasarca. IMPRESSION: 1. Mild-to-moderate right pleural effusion; however, interval decrease size compared prior. 2. Moderate ascites interval increase. 3. drainable fluid collection, however, evaluation suboptimal due lack IV oral contrast. 4. Diverticulosis. 5. Interval increase size small fat-containing umbilical hernia mild fat stranding, correlate point tenderness. 6. bowel obstruction. definite bowel wall thickening, although examination suboptimal such. 7. Pericardial effusion, similar prior. RUQ ultrasound [2174-4-18]: FINDINGS: liver normal echogenicity. Previously described presumably focal nodular hyperplasia segment VI liver clearly visualized. intra- extra-hepatic biliary duct dilatation. common bile duct measures 2 mm. ascites. gallbladder wall edema/thickening presumably third spacing; gallbadder distended. convincing evidence sludge ultrasound. main portal vein patent. Pancreas suboptimally evaluated due overlapping bowel gas. small-to-moderate right pleural effusion seen recent CT. IMPRESSION: 1. Ascites. 2. Gallbladder wall edema presumably third spacing. 3. Small-to-moderate right pleural effusion. 4. biliary duct dilatation. 5. Previously described presummed focal nodular hyperplasia segment VI liver clearly visualized. Small bowel follow [2174-4-20]: IMPRESSION: 1. Small, anterior cervical web hinder passage 13mm barium tablet. 2. Filling defect mid esophagus carina appears either extrinsic compression versus submucosal lesion. correlation comparison CT torso, mediastinal lesion less likely. Submucosal esophageal lesion remains within differential, direct visualization EGD recommended. possibility includes aberrant vessel vicinity. 3. Mobile cecum appear obstructive manner today's examination. Renal ultrasound [2174-4-20]: FINDINGS: right kidney measures 10.5 cm. left kidney measures 9.7 cm. evidence hydronephrosis, stone mass bilaterally. bladder unremarkable. Moderate amount ascites incidentally noted. IMPRESSION: hydronephrosis, stone mass within kidneys. Peritoneal Fluid [2174-4-25]: ATYPICAL. Scattered atypical lymphoid cells background reactive mesothelial cells IR guided paracentesis [2174-4-25]: IMPRESSION: Ultrasound-guided diagnostic paracentesis, total 200 mL ascites removed. TTE [2174-5-2]: left atrium mildly elongated. Left ventricular wall thicknesses cavity size normal. severe global left ventricular hypokinesis (LVEF = 20 %). Systolic function apical segments relatively preserved. masses thrombi seen left ventricle. Right ventricular chamber size mildly increased moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function likely depressed given severity tricuspid regurgitation.] aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. Severe [4+] tricuspid regurgitation seen. mild pulmonary artery systolic hypertension [In setting least moderate severe tricuspid regurgitation, estimated pulmonary artery systolic pressure may underestimated due high right atrial pressure.] small circumferential pericardial effusion without echocardiographic signs tamponade. IMPRESSION: Severe biventricular global hypokinesis. Severe tricuspid regurgitation. Pulmonary artery systolic hypertension. Small circumferential pericardial effusion without evidence tamponade physiology. Compared prior study (images reviewed) [2174-4-1], findings similar. TTE [2174-5-10]: left atrium dilated. left-to-right shunt across interatrial septum seen rest consistent stretched patent foramen ovale (or small atrial septal defect). mild symmetric left ventricular hypertrophy. left ventricular cavity size normal mildly impaired global left ventricular systolic function. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. tricuspid valve leaflets mildly thickened. moderate (2+) tricuspid regurgitation. mild pulmonary artery systolic hypertension. small pericardial effusion. echocardiographic signs tamponade. Echocardiographic signs tamponade may absent presence elevated right sided pressures. Compared prior study (images reviewed) [2174-5-6], ther pericardial effusion smaller. Biventricular sysotolic function appears slightly less vigorous compared prior study (on lower dose milrinone prior study). Cardiac cath [2174-5-5]: COMMENTS: 1. Hemodynamics measurements patient demonstrate low cardiac output. Following administration milrinone, cardiac index increased low-normal range 2.5 L/min/m2. 2. Moderate pulmonary hypertension right atrial v-waves consistent severe TR noted. Pulmonary vascular resistance elevated 280 dyne-cm-sec5. FINAL DIAGNOSIS: 1. Severe systolic ventricular dysfunction. 2. Moderate diastolic ventricular dysfunction. 3. Pulmonary hypertension LE ultrasound [2174-5-13]: IMPRESSION: 1. evidence deep venous thrombosis either lower extremity. 2. 3.6 cm [Hospital Ward Name 4675] cyst right popliteal fossa previous. Superficial soft tissue edema right mid thigh, may related partial rupture [Hospital Ward Name 4675] cyst. TTE [2174-5-16]: left atrium dilated. Left ventricular wall thicknesses cavity size normal. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets structurally normal. mitral valve prolapse. Trivial mitral regurgitation seen. Moderate [2+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. small pericardial effusion. effusion appears circumferential. echocardiographic signs tamponade. Echocardiographic signs tamponade may absent presence elevated right sided pressures. Compared prior study (images reviewed) [2174-5-10], biventricular systolic function slightly worse. size pericardial effusion slightly smaller. Brief Hospital Course: 38 yo F w/ h/o remission s/p cord transplant [1-13], anthracycline-induced cardiomyopathy (EF 15-20% [1-14]) recurrent nausea vomiting presents 1 week abd pain, acute chronic renal failure new hyperbilirubinemia. Unclear unifying diagnosis. # Acute Chronic Abdominal Pain: Pt noted significant abdominal pain well increased [Month/Year (2) 4394] admission. note, extensive work chronic abdominal pain past clear cause. Abdominal CT unrevealing obvious source pain. GI consulted recommended SBFT reveal significant pathology. GI recommended bentyl antispasmodic effect. also continued home MS contin IV morphine breakthrough. pain persisted [Last Name (LF) 4394], [First Name3 (LF) ] decision made perform diagnositc paracentesis ultrasound guidance. 200ml peritoneal fluid removed. revealed 775 WBCs, lymphocytic/monocytic predominance 1% polys making SBP unlikely. Fluid sent culture showed growth flow cytometry showed evidence recurrence. Despite lack evidence SBP, started zosyn empirically stopped [5-2]. continued mild-moderate abdominal pain able eat full meals BMs. continued home mscontin morphine IR. . # Anthracycline-induced/ GVHD cardiomyopathy: EF <20% echo 2/[2174]. Pt maintained diuresis above, subsequently held setting rising creatinine improvement creatinine. Torsemide slowly reintroduced uptitrated 40mg [Hospital1 ] caused another bump creatinine 3.0, renal cardiology consulted. Renal ultrasound unrevealing. taken Cath lab placed milrinone/lasix gtt transfered CCU. volume overload slowly improved peripheral edema/ascites slowly improved well. repeat echo showed improved EF 40-45% milrinone gtt. started solumedrol 30mg IV due concern GVHD directed towards myocardium. discussion cardiology oncology team also started cellcept management GVHD. well milrinone lasix drip, drip stopped creatinine bumped 3.0 felt volume status near maximization. milrinone discontiued transferred back [Hospital1 3242] management abdominal pain GVHD. continued torsemide diuresis close follow-up outpatient cardiologist. note, frequent alarms telemetry tachycardia cardiologist felt mostly due artifact; beta blocker uptitrated. Repeat TTE prior discharge showed EF 35-40%. discharged home cellcept prednisone possible GVHD. # Acute Renal Failure: admission Cr 2.7 (recent baseline 2), last discharge Cr 2.3. Renal saw patient thought likely overdiuresis (home torsemide regimen 20mg [Hospital1 ]) conjunction [Last Name (LF) ], [First Name3 (LF) ] recommended holding diuresis. Cr subsequently improved, setting worsening [First Name3 (LF) 4394] cardiomyopathy, decision made slowly add back diuresis, eventually titrated toresemide 40mg [Hospital1 ] [Last Name (un) ] restarted. this, however, Cr began climb 3.0. Given delicate balance renal failure cardiomyopathy, cardiology/renal consulted. Given depressed EF, rising Cr thought [3-9] volume overload. sent cath lab started milrinone/lasix gtt transfered CCU goal diuresis 1L per day. actively diuresed milrinone lasix drip total net negative close 9L. Cr returned baseline time discharge discharged home torsemide. # Hyperbilirubinemia: Unclear cause, could related viral infection transaminitis support this. RUQ u/s without cause pain. trended normal values remained stable time discharge # Leukocytosis: patient uptrending WBC setting starting solumedrol, clutures sent revealed growth. . # H/O Embolic Stroke: new opening PFO based recent echo likely contributed recent stroke. maintained coumadin 4mg daily, anticoagulation held day paracentesis remained subtherapeutic several days, maintained heparin drip bridge therapeutic INR [3-10]. maintained decreased dose coumadin throughout hospital admission INR within goal 2 3. arranged follow-up outpatient [Hospital3 ]. Medications Admission: Carvedilol 25 mg [Hospital1 ] Fluticasone-salmeterol [Hospital1 ] Morphine 15 mg q6h prn pain Valsartan 40 mg qd Torsemide 20 mg [Hospital1 ] Multivitamin qd Albuterol prn Lorazepam 0.5 mg q6h prn nausea Warfarin 4 mg qd Ondansetron 8 mg tid prn Pentamidine 300 mg inhalation qmonth Colace 100 mg qd prn Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk Device Sig: One (1) Disk Device Inhalation [Hospital1 ] (2 times day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed nausea. Disp:60 Tablet(s) Refills:0 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) needed sob wheeze. 5. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours needed nausea. 6. multivitamin Tablet Sig: One (1) Tablet PO day. 7. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:0 8. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). Disp:60 Tablet Extended Release(s) Refills:0 9. dicyclomine 20 mg Tablet Sig: One (1) Tablet PO four times day. Disp:120 Tablet(s) Refills:0 10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times day) needed abdominal pain gas. Disp:120 Tablet, Chewable(s) Refills:0 15. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). Disp:120 Tablet(s) Refills:0 16. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) needed constipation. Disp:500 ML(s) Refills:0 18. morphine 15 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours needed pain. 19. warfarin 2 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: -Abdominal Pain -Acute chronic renal failure -Systolic Heart failure Secondary: -ALL -History embolic stroke Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], admitted hospital abdominal pain. pain treated pain medications, new medication called Bentyl. also switched longer acting form morphine. test look small bowel negative. point sure causing pain, increased swelling abdomen likely contributed pain. underwent right heart catheterization [Known lastname 461] assess heart function worsening heart failure cause fluid belly worsening kidney disease. cardiac intensive care unit placed medication improved heart function. repeat [Known lastname 461] prior discharge showed heart function improved somewhat stable. follow closely cardiologist several heart medications changed. started steroids mycophenolate mofetil felt heart problems may due leukemia. also worsening renal failure. followed kidney consult team hospital. kidney function stable prior discharge. made following changes medications: -Mycophenolate Mofetil 1000mg twice day started -Prednisone 60mg daily started -Coumadin decreased 2mg daily -Torsemide increased 40mg daily -Please hold valsartan see cardiologist -Metoprolol succinate 100mg daily started; please stop carvedilol -Bentyl (dicyclomine) started abdominal pain -Simethicone started abdominal discomfort/gas -Your morphine switched long-acting Morphine 15mg twice day -Bactrim single strength, 1 tablet daily, started help prevent infection -Acyclovir 400mg twice day started help prevent infection -Allopurinol 100mg daily started uric acid levels high Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs. Followup Instructions: following appointments [Name8 (MD) 1988] you. need follow [Hospital3 ] Thursday, [2174-5-19], INR (coumadin level) check. Please come [Hospital Ward Name 23] Center [Location (un) 895] lab test 9am 5pm. Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2174-5-20] 3:30 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2174-5-20] 3:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10565], NP [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] MD, Cardiology [Last Name (LF) 766], [2174-5-30] 11:00AM SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] Department: WEST [Hospital 2002] CLINIC When: THURSDAY [2174-6-9] 10:00 With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] Completed by:[2174-5-26]	[ "5849", "4280" ]
Admission Date: [2193-6-27] Discharge Date: [2193-6-30] Date Birth: [2162-12-8] Sex: Service: SURGERY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: chest, lower back hip pain, s/p crush injury Major Surgical Invasive Procedure: none History Present Illness: Mr. [Known lastname 88968] 30 year old man untreated hypertension suffered crush injury chest (tractor loaded weight rolled onto chest) requiring extraction fork lift. denied LOC; VS stable [Location (un) ]. Upon ED presentation, c/o hip low back pain, yet denied chest pain, dyspnea, abdominal pain, headache neck pain. Cardiology consulted given concern contusion, cardiac injury. noted new RBBB ECG TWI. patient CPK 1464 TnT<0.01. MB 5. Pt's chest pain improved narcotics. also denied dyspnea, although hurts take deep breath. stopped taking anti-hypertensives lack insurance. atypical chest pains past evaluated [Hospital1 ] ECG. Denies exertional chest symptoms. orthopnea PND. Remaining ROS positive back pain pain hips. ROS negative. Past Medical History: HTN (not currently treated) Social History: Married (wife, [Name (NI) ] [Name (NI) 88969], [Telephone/Fax (1) 88970] emergency contact). Non-smoker, alcohol. illicits. Family History: premature CAD. Physical Exam: HEENT: Pupils equal, round reactive light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear auscultation Cardiovascular: Regular Rate Rhythm Abdominal: Soft, Nontender GU/Flank: costovertebral angle tenderness Extr/Back: cyanosis, clubbing edema Neuro: Speech fluent Pertinent Results: [2193-6-27] 02:03PM BLOOD WBC-5.0 RBC-5.25 Hgb-15.0 Hct-42.7 MCV-81* MCH-28.6 MCHC-35.2* RDW-14.0 Plt Ct-225 [2193-6-27] 02:10PM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0 [2193-6-27] 02:03PM BLOOD Plt Ct-225 [2193-6-27] 09:36PM BLOOD Glucose-111* UreaN-7 Creat-1.0 Na-140 K-3.2* Cl-108 HCO3-23 AnGap-12 [2193-6-27] 09:36PM BLOOD Glucose-674* UreaN-7 Creat-1.0 Na-136 K-2.6* Cl-102 HCO3-28 AnGap-9 [2193-6-27] 02:03PM BLOOD UreaN-10 Creat-1.3* [2193-6-27] 09:36PM BLOOD CK(CPK)-909* [2193-6-27] 02:03PM BLOOD ALT-40 AST-42* CK(CPK)-1464* AlkPhos-64 TotBili-0.6 [2193-6-27] 02:03PM BLOOD Lipase-48 [2193-6-27] 09:36PM BLOOD CK-MB-5 cTropnT-<0.01 [2193-6-27] 02:03PM BLOOD cTropnT-<0.01 [2193-6-27] 09:36PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9 [2193-6-27] 09:36PM BLOOD Calcium-6.8* Phos-1.8* Mg-1.6 [2193-6-27] 02:03PM BLOOD Calcium-9.1 [2193-6-27] 02:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2193-6-27] 02:10PM BLOOD Glucose-105 Lactate-1.5 Na-145 K-3.5 Cl-107 [2193-6-27] 02:10PM BLOOD Hgb-14.8 calcHCT-44 . [2193-6-27] 09:36PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.013 [2193-6-27] 02:24PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2193-6-27] 09:36PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [2193-6-27] 02:24PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [2193-6-27] 09:36PM URINE RBC-12* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2193-6-27] 02:24PM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [2193-6-27] 02:24PM URINE Mucous-RARE [2193-6-27] 02:24PM URINE Hours-RANDOM . [2193-6-27] 9:36 pm MRSA SCREEN; Source: Nasal swab. (Final [2193-6-30]): MRSA isolated. . [2193-6-28] 11:25AM BLOOD WBC-4.3 RBC-5.24 Hgb-15.1 Hct-44.0 MCV-84 MCH-28.8 MCHC-34.2 RDW-14.4 Plt Ct-228 [2193-6-28] 11:25AM BLOOD Plt Ct-228 [2193-6-28] 11:25AM BLOOD Glucose-133* UreaN-5* Creat-1.0 Na-142 K-3.6 Cl-109* HCO3-25 AnGap-12 [2193-6-28] 11:25AM BLOOD CK(CPK)-718* [2193-6-28] 04:47AM BLOOD CK(CPK)-827* [2193-6-28] 11:25AM BLOOD CK-MB-5 cTropnT-<0.01 [2193-6-28] 04:47AM BLOOD CK-MB-5 cTropnT-<0.01 [2193-6-28] 11:25AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.2 [2193-6-28] 04:50AM BLOOD Type-[Last Name (un) ] pH-7.32* [2193-6-28] 04:50AM BLOOD freeCa-1.11* . [2193-6-28] 09:57AM URINE Hours-RANDOM [2193-6-28] 09:57AM URINE Myoglob-PRESUMPTIVE . [2193-6-29] 05:55AM BLOOD WBC-5.9 RBC-5.40 Hgb-15.2 Hct-44.6 MCV-83 MCH-28.2 MCHC-34.2 RDW-14.2 Plt Ct-220 [2193-6-29] 05:55AM BLOOD Plt Ct-220 [2193-6-29] 05:55AM BLOOD [2193-6-29] 05:55AM BLOOD Glucose-87 UreaN-15 Creat-1.2 Na-141 K-3.6 Cl-107 HCO3-25 AnGap-13 [2193-6-29] 05:55AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1 . [2193-6-27] Cardiology ECG Sinus rhythm. Right bundle-branch block left anterior fascicular block. Probable left ventricular hypertrophy. previous tracing available comparison. Rate 67, PR 192, QRS 170, QT/QTc 424/436, P 65, QRS -72, -26 . [2193-6-27] 1:45 PM, TRAUMA #2 (AP CXR & PELVIS PORT) IMPRESSION: acute intrathoracic pelvic injury. . [2193-6-27] 1:59 PM, CT HEAD W/O CONTRAST IMPRESSION: acute intracranial injury skull fracture. . [2193-6-27] 2:00 PM, CT ABD & PELVIS CONTRAST, CT CHEST W/CONTRAST IMPRESSION: acute injury chest, abdomen pelvis. acute fracture. . [2193-6-27] 2:00 PM, CT C-SPINE W/O CONTRAST IMPRESSION: acute fracture malalignment. . [2193-6-27] 5:01 PM, MR CERVICAL SPINE W/O CONTRAST [2193-6-27] 5:01 PM, MR L SPINE W/O CONTRAST [2193-6-27] 5:01 PM, MR THORACIC SPINE W/O CONTRAST IMPRESSION: 1. evidence fracture ligamentus injury. 2. Mild degenerative changes spine. . [2193-6-28] 10:02:43 AM, ECHO, Portable TTE (Complete) IMPRESSION: RV systolic dysfunction pericardial effusion suggest significant cardiac contusion. Symmetric left ventricular hypertrophy mild global systolic dysfunction. Dilated thoracic aorta mild functional aortic regurgitation. Mild mitral regurgitation. findings consistent hypertensive heart disease. . [2193-6-28] Cardiology ECG Sinus rhythm. Right bundle-branch block left anterior fascicular block. Compared previous tracing change. Brief Hospital Course: Mr. [Known lastname 88968] 30 year old man untreated hypertension suffered crush injury chest (tractor loaded weight rolled onto chest) requiring extraction fork lift. denied LOC; VS stable [Location (un) ]. Upon ED presentation, c/o hip low back pain, yet denied chest pain, dyspnea, abdominal pain, headache neck pain. Cardiology consulted, given concern cardiac contusion, injury. Assesment: chronic RBBB HTN versus RV contusion conduction delay RV. LV function appeared normal. Hx c/w acute coronary syndrome. noted new RBBB ECG TWI. CPK 1464 TnT<0.01, MB 5, AST 42, Ca 9.1, 3 RBC urine, Cr 1.3, Hct 42.7. patient initially managed TICU close fluid status monitoring. patient hemodynamically stable. received agressive hydration goal Uop >100cc/hr. patient's pain controlled HD2, patient better. CKs cycled trending down. Creatinine normalized, IVF rate cut back. patient's diet advanced transitioned po pain meds transferred floor. floor, tolerated regular diet, ambulating physical therapy. continued intermittent muscular pain chest, lower back, hips, unchanged previous days. pain controlled oral narcotic pain medications. CT imaging MRI spine showed fracture ligamentous injury, CT show acute injury fracture chest, abdomen, pelvis. ready discharge [2193-6-30] home. Medications Admission: none Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times day). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. Disp:40 Tablet(s) Refills:0 3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed muscle spasm. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: rhabdomyolysis muscular pain Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted ACS service. fractures organ injuries seen imaging. may feel lot muscular aches next couple weeks body heals. Please resume home medications. take prescribed narcotic pain, drive operate heavy machinery taking medication. also take tylenol ibuprofen pain, exceed 4g tylenol per day. Followup Instructions: Follow-up acute care surgery clinic needed: [Telephone/Fax (1) 600]. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2193-6-30]	[ "4019" ]
Admission Date: [2140-12-8] Discharge Date: [2140-12-12] Date Birth: [2076-5-24] Sex: Service: CT SURGERY HISTORY PRESENT ILLNESS: Mr. [Known lastname 24524] 64-year-old male history progressive exertional dyspnea quitting smoking approximately six months ago. Workup exertional dyspnea included exercise treadmill test ultimately positive ischemic changes well echocardiogram subsequently elective cardiac catheterization. Cardiac catheterization completed [2140-12-5] showed left main coronary artery disease modest calcification distal 50% taper. left anterior descending also moderate calcification proximal 70% lesion D1 R1. D2 moderate vessel 90% proximal tubular lesions, D1 R1 ectatic proximal vessel large distal vessel. left circumflex artery nondominant vessel proximal 90% lesion moderate calcification well. right coronary artery dominant vessel, total proximal occlusion bridging left-right collaterals. posterior descending artery known good target. Additional findings catheterization abdominal aorta large infrarenal aneurysm beginning 13 mm renals, bilaterally single without disease. largest extent aneurysm 4.8 cm length 11.7 cm. Proximal runoffs reveals moderate ostial left iliac lesion. common femoral artery superficial femoral artery bilaterally normal. Given patient's significant three vessel coronary artery disease symptoms occasional angina dyspnea exertion, determined would appropriate candidate coronary artery bypass grafting. Cardiothoracic Surgery service consulted catheterization procedure, following history obtained. PAST MEDICAL HISTORY: History inferior myocardial infarction electrocardiogram, mild chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, 6 cm infrarenal abdominal aortic aneurysm noted previously picked incidentally examination cardiologist several months ago, benign prostatic hypertrophy, gout, greater 75 pack year smoking history recently quit last six months. hypothyroid. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: Aspirin 325 mg mouth daily, Lipitor 10 mg mouth daily, atenolol 50 mg mouth daily, allopurinol 100 mg mouth daily, Flomax .4 mg mouth daily, Tapazole 20 mg mouth daily, Mavik 1 mg mouth daily. LABORATORY DATA: Preoperative hematocrit 36. BUN creatinine 17 1.1. Catheterization data stated. Chest x-ray showed acute cardiopulmonary process. electrocardiogram significant sinus bradycardia 54, Q waves II, III AVF. abnormal ST/T wave changes. early J-point elevation. early R wave progression well. PHYSICAL EXAMINATION: Heart rate 54, blood pressure 134/70, acute distress, chest pain, carotid bruits auscultated. heart regular, prominent S2, murmur. lungs clear auscultation except decreased breath sounds throughout. abdominal examination soft, nontender, nondistended. pulsatile mass palpated xiphoid umbilicus, approximately 5 cm examination. hepatosplenomegaly, renal bruit. Flank examination negative. lower extremities palpable dorsalis pedis posterior tibial pulses distally bilaterally. HOSPITAL COURSE: Given presentation, elected bring operating room [2140-12-8]. first discharged elective catheterization [2140-12-5] ultimately readmitted [2140-12-8], underwent elective coronary artery bypass graft x 4 Dr. [Last Name (STitle) ], including left internal mammary artery left anterior descending, right saphenous vein graft diagonal, well saphenous vein graft obtuse marginal saphenous vein graft right posterior descending artery. patient tolerated procedure well. Intraoperative findings transesophageal echocardiogram ejection fraction 45 50%, calcified aorta, good distal targets. pericardium left open. right radial A-line. right internal jugular cordis place, CVP, right atrial catheter. two ventricular wires two atrial wires, two mediastinal tubes one pleural tube. mean arterial pressure 77, right atrial pressure 9. found normal sinus rhythm rate 74. propofol drip 20 mcg/kg/minute sedation. transferred Cardiac Surgical Recovery Unit, first 24 hours surgery, drips weaned rapidly extubated. remained sinus rhythm 88, blood pressures 120s 130s. hematocrit 25 postoperatively, BUN creatinine 18 1. Neurologically, remained intact. started lasix, Lopressor, aspirin. Chest tubes removed, well diet advanced. subsequently transferred floor postoperative day number one. ambulating postoperative day number one, feeling well. worked Physical Therapy aggressively, continued pulmonary toilet incentive spirometry, coughing deep breathing. electrolytes repleted needed. postoperative day number two, continued feel well. low-grade temperature 100.9, otherwise remainder vitals normal, heart rate 94 sinus, blood pressure 114/60. Lopressor titrated accordingly. BUN creatinine 23 1.0, hematocrit 24. postoperative day number four, patient ambulating. wires, chest tubes Foley removed point. sinus tachycardia sinus rhythm, 90 103. blood pressure ranging 106 110 50s 60s. Oxygen saturation 95% room air. stable sternum, evidence drainage. abdominal examination unchanged admission. extremities warm well perfused, palpable pulses dorsalis pedis posterior tibial bilaterally. Subsequently patient deemed stable appropriate discharge. DISCHARGE MEDICATIONS: Lopressor 75 mg mouth twice day, Lipitor 10 mg mouth daily, lasix 20 mg mouth daily seven days, K-Dur 20 mEq mouth daily seven days, Protonix 40 mg mouth daily, aspirin 325 mg mouth daily, allopurinol 100 mg mouth daily, Tapazole 20 mg mouth daily, Flomax .4 mg mouth daily, percocet 5/325 one two tablets mouth every four six hours needed, Colace 100 mg mouth twice day. DISCHARGE STATUS: home VNA. CONDITION DISCHARGE: Stable, afebrile, normal sinus rhythm, evidence sternal drainage. DISPOSITION: home VNA instructions undergo heavy lifting greater ten pounds 30 days, driving 30 days. Wound may get wet shower. follow Dr. [Last Name (STitle) ] four weeks, follow cardiologist primary care physician three weeks time discharge. VNA assist patient. happen dismiss day seven ten, return Wound Care Clinic, receive wound checkup. DISCHARGE DIAGNOSIS: 1. Significant three vessel coronary artery disease status post coronary artery bypass graft x 4, left internal mammary artery left anterior descending, saphenous vein graft diagonal, obtuse marginal also right posterior descending artery. 2. Hypertension 3. Hyperlipidemia 4. 6 cm abdominal aortic aneurysm 5. Benign prostatic hypertrophy 6. Mild chronic obstructive pulmonary disease 7. 50 pack year smoker 8. History inferior myocardial infarction coronary artery disease 9. Hypothyroidism 10. Questionable history osteoarthritis [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern4) 3204] MEDQUIST36 D: [2140-12-11] 22:42 T: [2140-12-12] 00:35 JOB#: [Job Number 24525]	[ "2449", "4019" ]
Admission Date: [2176-2-5] Discharge Date: [2176-2-15] Date Birth: [2106-8-2] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents Attending:[First Name3 (LF) 2181] Chief Complaint: Mental status changes Major Surgical Invasive Procedure: Intubation History Present Illness: 69 yo F history ESRD HD, DM, recently admitted [Hospital1 18] ORIF left distal femur fracture (uncomplicated hospital course) referred ED today developed acute change mental status associated decreased responsiveness dialysis treatment today. History per daughter stated last spoke mother night PTA "fine" (asking daughter finances, etc.). denies mother ever seizure, stroke past. Denies baseline weakness numbness. States patient living prior recent hip fracture. . Per sparse history dialysis notes, patient given percocet approximately 9:55AM approximately 10:30AM developed acute mental status changes, including confusion. Patient continued dialysis stable vital signs (BP 130's-140's/60's, HR 40's-50's). completion dialysis, EMS called transfer hospital. . EMS notes significant noting "rapid deterioration mental status", right gaze, dry blood lips, response pain, aphasia. EMS noted decreased HR 30's x 2 transfer, FSBS = 185. . presentation ED [Hospital1 18], exam notable minimal responsiveness, GCS 13, withdrawl extremities pain, following occasional commands, non-verbal (groans). VSS 98.8, HR 58, BP 132/102, O2 sat 98%. Labs notable WBC 9.5 86 N 2 B, Cr 5.1 (hx ESRD HD), AST 59, LDH 450, AP 218, bili 3.9, lactate 2.8. Blood cxs x 2 sent ED. Head CT demonstrated evidence intracranial bleed edema. CXR wnl. MRI/A scan performed (read pending). Evaluation neuro yielded diagnosis possible seizure activity. Pt given narcan 0.4mg IV x 1, Ativan total 2mg IV, dilantin load (total 2gm IV). intubated airway protection (given FFP prior intubation INR 1.9, coumadin outpt s/p hip surgery) transferred ICU managment. Past Medical History: 1. Diabetes type 2 2. ESRD HD Q M,W,F 3. s/p infection left knee 4. h/o MRSA/C.diff 5. NASH [3-7] tylenol 6. s/p ORIF left distal femur fracture [2176-1-23] Social History: SOH: lives home daughters. [Name (NI) ] ETOH/TOB/illicts. Family History: FH: non-contributory Physical Exam: Gen- intubated sedated HEENT- Pinpoint pupils, reactive b/l. 2 cm healed scar R upper forehead. c/d/i Neck- Supple, unable assess JVP Chest- CLA anteriorly, b/l CV- Regular, bradycardic. m/r/g Abd- +bs. soft. nd. hepatosplenomegaly. masses [Name (NI) ]- 1+ le edema. 2+ dp pulses. . transfer floor: Physical Exam: VS: BP 131-143/41-57, HR 74-85 RR 20 O2 92-96% RA Gen - lying bed, slurred speech, intermittently opens eyes, intermittently answers questions HEENT - PERRLA. 2 cm healed scar R upper forehead. anicteric sclerae Neck - Supple, unable assess JVP, patient left subclavian line Chest - decreased breath sounds left base CV - RRR, S1S2 normal, systolic murmur [4-8] radiating axillae Abd - +bs. soft. nd. hepatosplenomegaly. masses, mild tenderness RUQ deep palpation. Ext - trace LE edema. 2+ dp pulses. Pertinent Results: [2176-2-5] 02:10PM PT-16.8* PTT-36.5* INR(PT)-1.9 [2176-2-5] 02:10PM PLT SMR-LOW PLT COUNT-149# [2176-2-5] 02:10PM NEUTS-86 BANDS-2 LYMPHS-5* MONOS-6 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2176-2-5] 02:10PM WBC-9.5# RBC-3.92* HGB-13.2# HCT-37.7# MCV-96 MCH-33.6* MCHC-35.0 RDW-20.1* [2176-2-5] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2176-2-5] 02:10PM T4-19.8* [2176-2-5] 02:10PM TSH-3.6 [2176-2-5] 02:10PM CALCIUM-9.4 PHOSPHATE-4.0# MAGNESIUM-1.8 [2176-2-5] 02:10PM LIPASE-524* [2176-2-5] 02:10PM ALT(SGPT)-15 AST(SGOT)-59* LD(LDH)-450* ALK PHOS-218* TOT BILI-3.9* [2176-2-5] 02:10PM GLUCOSE-186* UREA N-29* CREAT-5.1* SODIUM-131* POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-22 ANION GAP-20 . Imaging: [2176-2-5] CT head w/out contrast: evidence intracranial hemorrhage edema. [2176-2-5] CXR: Unremarkable chest radiograph. [2176-2-5] MRI brain w/out contrast [2176-2-5]: evidence acute brain ischemia. Small arachnoid cyst right cerebellopontine angle cistern. Limited MR angiography study- distal vasculature poorly visualized, could secondary low cardiac output. [2176-2-6] Liver U/S - Limited examination. Patent hepatic arteries veins portal veins flow appropriate direction. [2176-2-7] EEG - Markedly abnormal portable EEG due slow disorganized background frequent generalized sharp wave discharges. findings indicate widespread encephalopathy affecting cortical subcortical structures. Medications, metabolic disturbances, infection among common causes. sharp waves prominent frequent suggest increased risk seizures. Nevertheless, particularly rhythmic higher frequency recording suggest ongoing seizures time recording. prominent focal findings although encephalopathies obscure findings. concern seizures persist clinically, repeat tracing could assistance. [2176-2-8] MR [Name13 (STitle) 430] - Severely limited study. large gross changes identified compared [2176-2-5], subtle acute changes discernable today's study. indeed high clinical suspicion acute change [2-5], repeat imaging may necessary. [2175-2-9] Abdominal U/S - ascites. Marked splenomegaly Brief Hospital Course: # Mental status change: Initial exam notable minimal responsiveness, withdrawal extremities pain, following occasional commands, non-verbal (groans). VSS 98.8, HR 58, BP 132/102, O2 sat 98%. Head CT demonstrated evidence intracranial bleed edema. CXR wnl. MRI/A scan performed show evidence ischemia. Evaluation neuro yielded diagnosis possible seizure activity. Pt given narcan 0.4mg IV x 1, Ativan total 2mg IV, dilantin load (total 2gm IV). intubated airway protection transferred ICU managment. also covered possible encephalitis/ meningitis Acyclovir, CTX, Vanco Ampicillin. LP done show signs meningitis encephalitis. pt continued waxing [Doctor Last Name 688] mental status. found elevated LFTs thought component hepatic encephalopathy. First EEG supporting seizure activity. Repeat EEG showed slowed activity c/w encephalopathy. Possible hepatic encephalopathy: Ammonia elevated 65, therefore pt started lactulose attempt improve MS. Repeat 30's. Abx discontinued. [2-8] pt self extubated reintubated extubated [2-9]. NG tube placed nutrition. following two days pt lucid stable. called floor management. pt continued improve became lucid oriented x3. Dilantin continued orally 300mg QD. Free Dilantin levels checked therapeutic levels therefore Dilantin increased 150 TID. Free Dilantin level repeated three days. Lactulose Rifaximin continued. Lactulose titrated three bowel movements. . # Liver disease: Per pt's daughter pt tylenol induced liver damage past. Per daughter ETOH/drug abuse past. Hep neg, B surface pos, core neg, Hep C neg. Serum IgG, IgA, IgM elevated without specific pattern suggestive disease process. [Doctor First Name ] negative, Anti-SM AMA mildly positive (Titer 1:20). HSV PCR negative. Possible primary biliary cirrhosis also consistent obstructive enzyme pattern. Also possible steatosis hepatis obesity. RUQ U/S showed splenomegaly, ascites, focal lesions liver, sign biliary dilatiation. Flow appropriate direction portal vein. LFTs followed trending down. Follow LFT, CBC Chem 7 obtained following week. pt follow arranged Dr. [Last Name (STitle) 497] [2-13] 9.40am. liver biopsy might considered investigate etiology problem further. pt given hepatitis vaccine stable. adviced avoid hepatotoxic medications. . # Transient Leukocytosis intermittent fever spike: Urine WBC, one time positive urine culture klebsiella. Pt initially treated suspected meningitis Ampicillin, Vancomycin Ceftraixone. Antiobiotics discontinued five days hospital course. pt afebrile discontinuation antibiotics remained normal WBC. pt found new systolic murmur exam, radiating axilla, consistent mild mitral regurgitation. Follow ECHO obtained. Given fact blood cultures negative pt remained afebrile physical signs examinations found consistent endocarditis suspicion endocarditis considered low workup obtained. . # ESRD: Pt continued outpatient dialysis schedule house. tolerated dialysis well. . # Hypernatremia: transient. Due lack free water prolonged initial period without feeding complicate NGT placement. Free water deficit calculated 4L. Pt repleted free water boluses via NGT 250cc TID. Hypernatremia resolved. . # Anemia - pt baseline anemia - three points decreased baseline around 29. Likely sequestration spleen possible low grade hemolysis due liver disease addition renal anemia ESRD. Hemolysis labs difficult interpret setting liver disease. Iron studies consistent anemia chronic disease, iron deficiency. Erythropoetin administered dialysis. . # Thrombocytopenia & elevated INR: HIT AB POSITIVE. Also splenomegaly chronic liver disease, likely sequestering. heparin containing products avoided. Thrombocytes consistently 50,000. . # DM2: Endocrinology consulted sliding scale adjusted per recommendations. Lantus 20 RISS continued outpatient. Pt one time episode hypoglycemia 49. ISSC decreased unit two days prior discharge. fine adjustment achieved rehabilitation center. . # ORIF: pt seen orthopedics house. Knee XR obtained. dislocation hardware seen. pt remain weight bearing L leg 5 weeks. F/u appointment ortho obtained 5 weeks. Medications Admission: 1. Colace 100 mg [Hospital1 ] 2. Pantoprazole 40 mg QD 3. Acetaminophen 500 mg q6 4. Metoprolol Tartrate 25 mg [Hospital1 ] 5. Warfarin 1 mg QD 6. Calcium Carbonate 500 mg TID 7. Hydromorphone 2 mg q6 8. Senna 8.6 mg [Hospital1 ] 9. Bisacodyl 10 mg Tablet, QD 10. Sevelamer 800 mg TID Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times day). Disp:180 Tablet(s) Refills:2 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times day). Disp:1350 ML(s) Refills:2 6. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous directed. Disp:qs Refills:2 7. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times day). Disp:270 Tablet, Chewable(s) Refills:2 8. Insulin Glargine 100 unit/mL Solution Sig: directed Subcutaneous bedtime. Disp:qs Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Mental status changes EEG seizure like activity Liver failure Hepatic encephalopathy ................... Diabetes type 2 ESRD HD Q M,W,F s/p ORIF left distal femur fracture [2176-1-23] Discharge Condition: Good, Pt [Name (NI) 9830]3, mental status changes resolved Discharge Instructions: Please come back hospital see primary care doctor experience worsening mental status, confusion, headaches, jaundice concerns. . Please take medications instructed. Followup Instructions: Please follow Dr. [Last Name (STitle) 497] [2-13] 9.40am liver disease. . Please follow Neurology, Dr. [Last Name (STitle) ] [3-22] 11.00am, [Location (un) ] [Hospital Ward Name 23] building. . Please also follow primary care doctor. . follow orthopedics fracture: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2176-3-19] 9:00	[ "5990" ]
Admission Date: [2179-9-19] Discharge Date: [2179-9-25] Date Birth: [2109-10-29] Sex: Service: CARDIOTHORACIC Allergies: Lipitor Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea exertion Major Surgical Invasive Procedure: [2180-9-18] Aortic Valve Replacement (23mm CE pericardial), Coronary Artery Bypass Graft x 1 (LIMA LAD) History Present Illness: 69 y/o male h/o atrial fibrillation, aortic stenosis, coronary artery disease increased symptoms dyspnea exertion. Along fatigue dizziness. referred surgical intervention. Past Medical History: Aortic Stenosis, Coronary Artery Disease, Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM [2174], Erectile Dysfunction s/p Hernia repair, s/p Bilat knee arthroscopy Social History: Denies tobacco ETOH use. Family History: NC Physical Exam: VS: 72 18 154/98 6' 195# Gen: WDWN male NAD Skin: Unremarkable HEENT: EOMI, PERRL NCAT Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB Cardiac: Irreg rhythm 3/6 SEM radiating carotids Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: grossly intact, A&O x 3 Pertinent Results: [2179-9-20] Echo: PREBYPASS: 1. left atrium normal size. spontaneous echo contrast thrombus seen body left atrium left atrial appendage. 2. Left ventricular wall thicknesses cavity size normal. Overall left ventricular systolic function low normal (LVEF 50-55%). Right ventricular chamber size free wall motion normal. 3. ascending transverse thoracic aorta normal diameter free atherosclerotic plaque. simple atheroma descending thoracic aorta. 4. three aortic valve leaflets, moderately thickened. severe aortic valve stenosis (area <0.8cm2). 5. Mild (1+) aortic regurgitation seen. mitral valve leaflets moderately thickened. 6. pericardial effusion. 7. Dr. [Last Name (STitle) ] notified person results [2179-9-20] 1209. POSTBYPASS: 1. Pt currently phenylephrine infusion 2. pt thickened LV walls underfilled ventricle. Wall motion unchanged prebypass, EF 50% 3. aortic annular ring seen well seated perivalvular leak. +1 Aortic insufficiency 4. contours aortic root smooth aortic cannular removed. [2179-9-21] CXR: compared previous radiograph, relevant change. monitoring support devices unchanged position. evidence pneumothorax evidence major pleural effusion. Subtle retrocardiac atelectasis. focal parenchymal opacities suggestive pneumonia. Mild overinflation stomach. [2179-9-19] 05:25PM BLOOD WBC-6.3 RBC-5.04 Hgb-15.7 Hct-44.2 MCV-88 MCH-31.2 MCHC-35.6* RDW-13.5 Plt Ct-210 [2179-9-22] 05:35AM BLOOD WBC-21.5# RBC-4.63 Hgb-14.0 Hct-41.6 MCV-90 MCH-30.3 MCHC-33.7 RDW-13.9 Plt Ct-142 [2179-9-19] 05:25PM BLOOD PT-15.1* PTT-30.8 INR(PT)-1.3* [2179-9-20] 09:11PM BLOOD PT-15.9* PTT-39.0* INR(PT)-1.4* [2179-9-19] 05:25PM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-142 K-3.9 Cl-108 HCO3-26 AnGap-12 [2179-9-22] 05:35AM BLOOD Glucose-153* UreaN-20 Creat-1.2 Na-133 K-4.5 Cl-100 HCO3-19* AnGap-19 [2179-9-19] 05:25PM BLOOD ALT-23 AST-23 LD(LDH)-203 AlkPhos-56 TotBili-0.9 [2179-9-25] 08:16AM BLOOD WBC-7.6 RBC-4.02* Hgb-12.1* Hct-35.8* MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt Ct-174# [2179-9-22] 12:27PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Brief Hospital Course: Mr. [Known lastname 1274] admitted day surgery d/t Coumadin h/o Atrial Fibrillation. discontinued 5 days surgery. Upon admission started Heparin appropriately worked surgery. [9-20] brought operating room underwent aortic valve replacement coronary artery bypass graft x 1. Please see operative report surgical details. Following surgery transferred CVICU invasive monitoring stable condition. Later op day weaned sedation, awoke neurologically intact extubated. post-op day one EP consulted interrogate pacemaker. Later day Mr. [Known lastname 1274] appeared well transferred telemetry floor care. Mr [Known lastname 1274] chronic afib difficult control metoprolol advanced. re-started coumadin POD 2. rub noticed started Ibuprofen.The remainder postoperative course essentially unremarkable. [9-22] due elevated WBC ct. blood urine cultures sent empiric antibiotics started. Urine Cx originally positive sensitive ABX repeat finalized negative. WBC ct improved normal temp.remained afebrile, time discharge blood cultures pending, decided continue full week antibiotic coverage. restared preoperative dose Digoxin, along preoperative Coumadin regiment 5 mg alt. 2.5 mg daily, VNA. advised follow appointments. Medications Admission: Atenolol 100mg [Hospital1 ], Prilosec 20mg qd, Tricor 146mg qd, Digoxin 0.25mg qd, Vit C, E, Zetia 10mg qd, Coumadin (stopped [9-14]) Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:1 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) needed. Disp:40 Tablet(s) Refills:0 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:1 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 7. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO day: resume 5mg alternating 2.5 mg daily [Name8 (MD) ] MD . Disp:90 Tablet(s) Refills:0 8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times day). Disp:225 Tablet(s) Refills:0 10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice day 7 days. Disp:28 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice day 7 days. Disp:28 Tab Sust.Rel. Particle/Crystal(s) Refills:0 12. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) 4 days. Disp:32 Capsule(s) Refills:0 Discharge Disposition: Home Service Facility: tba Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1 PMH: Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM [2174], Erectile Dysfunction s/p Hernia repair, s/p Bilat knee arthroscopy Discharge Condition: good Discharge Instructions: Monitor wounds signs infection. include redness, drainage increased pain. event drainage sternal wound, please contact [Name2 (NI) 5059] ([Telephone/Fax (1) 4044]. Report fever greater 100.5. Report weight gain 2 pounds 24 hours 5 pounds 1 week. lotions, creams powders incision healed. Shower daily. baths swimming.Gently pat wound dry. lifting greater 10 pounds 10 weeks. driving 1 month Take medications directed Followup Instructions: wound clinic 2 weeks Dr [Last Name (STitle) ] 4 weeks Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469] [2-14] weeks Completed by:[2179-9-25]	[ "4280", "5990" ]
Admission Date: [2198-2-1] Discharge Date: [2198-2-19] Date Birth: [2129-10-28] Sex: Service: CSU HISTORY PRESENT ILLNESS: 68 year old white male abnormal stress test 02/[2194]. underwent cardiac cath revealed 100 percent RCA lesion. angina [2196] abnormal stress test re- cathed, showed 100 percent RCA lesion, 50 percent left main stenosis, left circumflex stenosis. symptoms surgery deferred. month angina abnormal treadmill EF 27 percent. angio [2198-1-31] revealed 95 percent ostia left main, 70 percent diagonal 2 lesion, 80 percent OM 100 percent RCA lesion normal LV. transferred [Hospital1 18] treatment. PAST MEDICAL HISTORY: past medical history significant history non-insulin dependent diabetes, hypercholesterolemia, hypertension, prostate CA, status post removal basal cell carcinoma back two weeks prior admission. also status post cataract surgery. MEDICATIONS: medications admission nitroglycerin drip, Metformin, Lipitor, aspirin, multivitamin, Metamucil, Atenolol. ALLERGIES: known allergies. FAMILY HISTORY: Family history significant coronary artery disease. SOCIAL HISTORY: smoke cigarettes drinks alcohol occasionally. REVIEW SYSTEMS: review systems above. PHYSICAL EXAMINATION: well developed, well nourished white male apparent distress. Vital signs stable. Afebrile. HEENT exam normocephalic atraumatic. Extraocular movements intact. Oropharynx benign. Neck supple. Full range motion. lymphadenopathy thyromegaly. Carotids 2 plus equal bilaterally without bruits. Lungs clear auscultation percussion. Cardiovascular exam regular rate rhythm. Normal S1 S2 rubs, murmurs gallops. Abdomen soft nontender positive bowel sounds. masses hepatosplenomegaly. Extremities without cyanosis, clubbing edema. Pulses 2 plus equal bilaterally throughout. Neuro exam nonfocal. HOSPITAL COURSE: Dr. [Last Name (STitle) ] consulted [2198-2-2] patient underwent CABG times five free LIMA LAD reverse saphenous vein graft diagonal, OM1, OM2 PVA. Cross clamp time 89 minutes. Total bypass time 125 minutes. transferred CSRU Neo stable condition. stable postop night. extubated. postoperative day one started beta blocker nitro weaned. Postop day two transferred floor stable condition chest tubes discontinued. Postop day three epicardial pacing wires discontinued. Postop day number four began sternal drainage. started Kefzol wounds painted Betadine tid. drainage lower two sternal wires seemed pulled x-ray, postop day number five underwent sternal re-wiring. tolerated procedure well transferred back floor. continued improve chest tubes discontinued postop day number one re-wiring. also changed Levofloxacin Vanco. continued improve continued intermittent sternal drainage. cultures negative. PICC line placed continued Vanco. Eventually drainage stopped completely two days drainage Vanco discontinued discharged home week Levofloxacin. postop day number 17 discharged home stable condition. LABORATORY DATA: labs discharge white count 10,000, hematocrit 28.1, platelets 767,000, sodium 139, potassium 5.2, chloride 104, CO2 28, BUN 17, creatinine 0.9, blood sugar 116. DISCHARGE MEDICATIONS: 1. Glucophage, 500 mg po bid. 2. Colace, 100 mg po bid. 3. Aspirin, 81 mg po q day. 4. Percocet, 1 2 po q4-6h prn pain. 5. Lipitor, 10 mg po q day. 6. Plavix, 75 mg po q day. 7. Lopressor, 100 mg po tid. 8. Lisinopril, 10 mg po q day. 9. Levofloxacin, 500 mg po q day 7 days. seen Dr. [Last Name (STitle) ] four weeks Dr. [Last Name (STitle) 37063] one two weeks. DISCHARGE DIAGNOSES: discharge diagnoses include: 1. Coronary artery disease. 2. Hypertension. 3. Hyperlipidemia. 4. Non-insulin dependent diabetes. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2198-2-19] 15:54:20 T: [2198-2-19] 16:33:56 Job#: [Job Number 58744]	[ "4019" ]
Admission Date: [2111-5-25] Discharge Date: [2111-5-29] Date Birth: [2063-5-8] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[First Name3 (LF) 30] Chief Complaint: Overdose Major Surgical Invasive Procedure: None History Present Illness: Pt 47 yo female chronic pain low back torticollis hospitalized 7 previous medication overdoses(always denies SI)(most recently 2 days ago) presents s/p OD combination meds (baclofen, vicodin, soma, fentanyl patches, methadone). Unclear suicide attempt, denied past ODs. recent hospitalization indicates o/d diazepam, methadone, baclofen. Today found halfway house staff "nodding off" minimally responsive (to sternal rub only). reports available. Unable contact halfway house o/n. Past Medical History: PMH: 1. Polysubstance overdose -- Pt 5 suicide attempts within five month period [2109]. Also recently admitted [Date range (1) 76337] overdose vicodin/soma/baclofen states suicide attempt, rather attempt control pain. 2. Substance abuse-EtOH. 3. Depression- Seen [Hospital1 1680] HRI Mind Body Institute 4. ? Bipolar disorder 5. Chronic buttock/back pain: trigger point injections lower back region. 6. Cervical torticollis: receives botox injections, severe left-sided head tilt together may compensatory tilt opposite direction thoracic spine. Pain region right sternomastoid right posterior cervical muscles. 7. Gastroesophageal reflux disease. 8. h/o MRSA sputum [2108], treated 9. h/o assault requiring ICU admit last year. 10. h/o multiple miscarriages, 1 late pregnancy, h/o 2 yo daughter drowning. 11. Recently started methadone pain control [2-17] . Providers: PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5781] [Company 191], [Telephone/Fax (1) 250] Neuro: Dr. [Last Name (STitle) ] [Hospital1 18], [Telephone/Fax (1) 1942] Ortho: Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1022], [Telephone/Fax (1) 7807] Spinal surgeon: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 28003] [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Management Service: Dr. [Last Name (STitle) ], [Telephone/Fax (1) 49911] . PSYCHIATRIC HISTORY: Diagnoses: depressed [Telephone/Fax (1) ], question bipolar disorder h/o alcohol abuse, narcotic abuse; sexual assault Hospitalizations: HRI, [Doctor Last Name 16471], [Hospital3 44097]. Suicide Attempts: patient denies Current [Hospital3 2447]: Dr. [Last Name (STitle) 105809] therapist: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 105810] [Location (un) 86] [Hospital1 1680] Trauma Center [Location (un) 577] [Telephone/Fax (1) 7353] (L/M hours line) Counselor: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 105817] Social History: Lives [Location 3952] House. Smokes [11-16] ppd 10 yrs. documented h/o EtOH abuse past, + abuse prescription meds Family History: NC Physical Exam: VS 95.0 117/59 78 14 98% 2L NC Gen: disheveled woman sleeping, responds painful/noxious stimuli HEENT: anicteric, PERRL --> 4mm B, OP clear w/ MMM CV: reg s1/s2, s3/s4/m/r Pulm: CTA B (poor effort), wheezes crackles Abd: +BS, soft, NT, ND Ext: warm, 2+ DP B, edema Neuro: responds noxious stimuli, + gag reflex, moves 4 extr. Pertinent Results: Pertinent Admission Labs: wbc 7.7, hct 33.5, INR 1.0. Serum ASA 9, Ammonia 26, Utox + benzo methadone (neg cocaine, opiates) LFTs: ALT 14, AST 19, A/P 98, Tbili 0.1 . EKG: NSR 80, nl axis, nl intervals, ST/T changes CXR: R atelectasis Brief Hospital Course: 47 y/o female chronic pain low back torticollis hospitalized 7 previous medication overdoses presents s/p likely OD minimal responsiveness. brief [Hospital 11822] hospital course outlined below. 1. mental status changes/respiratory depression: Likely secondary medication effects substance abuse/overdose. note initial tox screen positive benzos methadone. Remainder tox screen negative. given narcan initially max dose 1mg/hr without increased responsiveness. Therefore discontinued. mental status gradually improved next 24 hours. note, need intubation respiratory support evidence withdrawl signs symptoms. kept diazepam 5mg q4prn CIWA scale > 12, however require valium. CIWA scale subsequently discontinued. benzos opioid analgesics stopped. 2. Psych: Initially held meds admission. Neurontin, lamictal, seroquel restarted upon improvement MS. Pt extensive psychiatric history including history polysubstance abuse OD. Psych consulted day admission - recommended 1:1 sitter, obtained. Also recommended holding giving benzos, addictive substances - per psych, unlikely patient withdraw long half life, although kept CIWA case. CIWA. Discontinued lamictal per psych recs. Increased seroquel dose symptoms anxiety. Plan section 35 patient mandatorily receive drug rehab. 3. Torticollis: Recieved botox injection Dr. [Last Name (STitle) ] hospital stay. Medications Admission: 1. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS (once day (at bedtime)). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO three times day. 4. Lamictal 25 mg Tablet Sig: One (1) Tablet PO day. 7 TABLETS 5. ASA prn Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times day). 3. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. 6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 8. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times day) needed. 9. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QAM (once day (in morning)). Discharge Disposition: Extended Care Discharge Diagnosis: primary diagnosis: 1. respiratory depression 2. altered mental status 3. substance abuse/overdose Secondary diagnosis: 1. torticollis 2. h/o suicide attempts 3. h/o substance abuse 4. depression 5. MRSA sputum [2108] Discharge Condition: section 35 involuntary detox Discharge Instructions: Report nausea, vomiting, fever, chills, shortness breath pain controlled current regimen medical issues primary physician. Followup Instructions: follow-up primary physician medical issues	[ "2859" ]
Admission Date: [2178-12-25] Discharge Date: [2178-12-27] Date Birth: [2116-2-19] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7055] Chief Complaint: Transfer [Hospital3 ] admitted atypical chest pain SOB Major Surgical Invasive Procedure: -Central venous line insertion R IJ -Multiple attempts securing arterial access History Present Illness: 62F hx severe pulm HTN, CAD s/p DES Lcx/LAD [10/2177], prior CVA s/p b/l CEA's, PVD, COPD admitted OSH [12-23] atypical chest pain SOB. ruled ACS enzymes (MB 8 -> 7 -> 5; Trop 0.06 -> 0.07 -> 0.06) EKG without acute ischemic changes found BNP 11K admission. assessed severe decompensated R-sided CHF diuresed 40mg IV lasix ED later day experienced [9-9] back pain desat 50's transferred CCU close monitoring HR 60's BP's 90's. ECHO [12-24] showed severe pulmonary hypertension, RV pressure overload, modestly depressed RV function, LVEF 55-65%. . CCU describes feeling gradually short breath past 2 months become acutely worse past 1-2 weeks. Interestingly, 1 month ago started sildenafil treatment pulm htn felt became short breath taking medication stopped taking 2 weeks ago started feeling acutely short breath. states gained 2-3lbs past two weeks noticed increased ankle swelling, increasing need oxygen (she usually 88-92 3LNC home prior past 2 weeks used oxygen night). 2 pillow orthopnea, denies PND. denies dietary indiscretion, recent illnesses, fevers, chills, cough, sputum production, symptoms. According family never low back pain problem patient states back pain gets better positional changes rubbing. Also, baseline daily function decreased normally able move around rooms house able walk 10 feet due shortness breath addition basleine vascular claudication. . review systems, s/he denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. S/he denies recent fevers, chills rigors. review systems negative. . Cardiac review systems notable absence chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: CAD s/p LAD cypher stenting - CABG: n/a - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: n/a 3. PAST MEDICAL HISTORY: -Occult SBE aortic valve vegetation -Severe pHTN -Severe PVD s/p multiple vascular surgeries -Rt Fem-[Doctor Last Name ] bypass -Rt CEA following CVA prior [2173] -Lt CEA following TIA [2173] -Stenting LCx DPromus [Name Prefix (Prefixes) ] -[Last Name (Prefixes) ] Prox/Mid LAD Promus Stent Social History: Pt livers two daughters home. Tob: 0.5ppd x40years (since age 17) EtOH: social - 2 beers every 2 weeks Illicit drug use: denies Family History: Father MI 50's stroke 60's. Siblings DM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=96.7 BP=103/66 HR=72 RR=10 O2 sat= 93% non-rebreather GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP earlobes CARDIAC: PMI located 5th intercostal space, midclavicular line. RR, normal S1, loud S2. m/r/g. S3 apex. thrills, lifts. LUNGS: Rales halfway bases ABDOMEN: Soft, obese, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: 2+ pitting mid shin, several old scars prior vascular surgery procedures. femoral bruits. SKIN: Mild stasis dermatitis changes. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable, PT dopplerable . DISCHARGE PHYSICAL EXAM: Patient expired. Pertinent Results: ADMISSION LABS: . [2178-12-25] 06:24PM BLOOD WBC-12.5* RBC-4.46 Hgb-11.4* Hct-35.8* MCV-80* MCH-25.5* MCHC-31.7 RDW-17.5* Plt Ct-348 [2178-12-25] 06:24PM BLOOD Neuts-77* Bands-0 Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* [2178-12-25] 06:24PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-OCCASIONAL Target-OCCASIONAL Burr-2+ [2178-12-25] 06:24PM BLOOD PT-17.0* PTT-34.3 INR(PT)-1.5* [2178-12-25] 06:24PM BLOOD Glucose-40* UreaN-45* Creat-1.8* Na-131* K-3.6 Cl-93* HCO3-22 AnGap-20 [2178-12-25] 06:24PM BLOOD CK(CPK)-180 [2178-12-26] 05:17AM BLOOD ALT-81* AST-65* LD(LDH)-365* CK(CPK)-149 AlkPhos-88 TotBili-1.2 [2178-12-25] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37* [2178-12-25] 06:24PM BLOOD Calcium-8.7 Phos-5.6* Mg-1.4* . PERTINENT LABS: . [2178-12-25] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37* [2178-12-26] 05:17AM BLOOD CK-MB-11* MB Indx-7.4* cTropnT-0.31* [2178-12-26] 08:54PM BLOOD CK-MB-9 cTropnT-0.35* [2178-12-27] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00* [2178-12-27] 04:23AM BLOOD Cortsol-32.8* [2178-12-27] 04:23AM BLOOD TSH-2.1 [2178-12-26] 05:41AM BLOOD Lactate-1.7 [2178-12-26] 03:52PM BLOOD Lactate-2.5* [2178-12-26] 11:26PM BLOOD Lactate-7.5* [2178-12-27] 01:50AM BLOOD Lactate-8.7* [2178-12-27] 04:24AM BLOOD Lactate-11.1* [2178-12-27] 05:05AM BLOOD Lactate-10.3* [2178-12-27] 11:38AM BLOOD Lactate-5.1* [2178-12-26] 03:52PM BLOOD Type-ART pO2-52* pCO2-35 pH-7.42 calTCO2-23 Base XS [2178-12-27] 01:50AM BLOOD Type-[Last Name (un) ] pO2-40* pCO2-69* pH-7.02* calTCO2-19* Base XS--15 [2178-12-27] 04:24AM BLOOD Type-CENTRAL pO2-53* pCO2-60* pH-7.10* calTCO2-20* Base XS--11 [2178-12-27] 05:05AM BLOOD Type-CENTRAL pO2-52* pCO2-58* pH-7.16* calTCO2-22 Base XS--8 [2178-12-27] 11:38AM BLOOD Type-[Last Name (un) ] pO2-42* pCO2-73* pH-7.20* calTCO2-30 Base XS--1 . DISCHARGE LABS: . [2178-12-27] 11:16AM BLOOD WBC-26.6# RBC-4.37 Hgb-11.3 Hct-36.8 MCV-84 MCH-25.8* MCHC-30.6* RDW-16.9* Plt Ct-335 [2178-12-27] 04:23AM BLOOD Glucose-506* UreaN-41* Creat-1.8* Na-131* K-4.2 Cl-89* HCO3-19* AnGap-27* [2178-12-27] 04:23AM BLOOD ALT-226* AST-262* LD(LDH)-905* CK(CPK)-288* AlkPhos-89 TotBili-1.7* [2178-12-27] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00* [2178-12-27] 04:23AM BLOOD Albumin-3.4* Calcium-8.1* Phos-7.3# Mg-2.5 [2178-12-27] 11:38AM BLOOD Type-[Last Name (un) ] pO2-42 pCO2-73* pH-7.20* calTCO2-30 Base XS--1 [2178-12-27] 11:38AM BLOOD Lactate-5.1* . MICRO/PATH: . Blood Cultures x 2: Pending MRSA Screen: Pending . IMAGING/STUDIES: . CXR Portable [12-25]: IMPRESSION: Mild interstitial pulmonary edema present, along small right pleural effusion, decreased since [9-5]. Heart size top normal, main pulmonary artery substantially dilated, indicating persistent pulmonary arterial hypertension. Previous mediastinal adenopathy documented chest CT [Month (only) 216] difficult assess probably worsened. pneumothorax. . Aorta/Branches U/S [12-25]: IMPRESSION: evidence abdominal aortic aneurysm. Atherosclerosis. . CXR Portable [12-25]: Tip new right internal jugular line ends region superior cavoatrial junction. pneumothorax increase small right pleural effusion. Interval increase mediastinal caliber due vascular engorgement, due elevated central venous pressure, probably function biventricular heart failure, reflected mild increase heart size, moderate increase pulmonary edema. Severe pulmonary atrial enlargement, indication marked pulmonary arterial hypertension, aortic valvular calcification, could hemodynamically significant (particularly setting decreased LV filling), severe, global coronary calcification shown Chest CT [Month (only) 216] [2178], discussed Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 30814] time dictation. . R LENI [12-26]: IMPRESSION: Limited assessment right lower extremity due early termination examination. DVT seen examined veins. . CXR Portable [12-27]: FINDINGS: comparison study [12-25], placement endotracheal tube tip upper clavicular level, approximately 6.5 cm carina. Nasogastric tube extends upper stomach, though side hole within lower portion esophagus. Continued enlargement cardiac silhouette substantial pulmonary arterial enlargement consistent pulmonary artery hypertension. moderate pulmonary edema well. . TTE [12-27]:The left atrium mildly dilated. estimated right atrial pressure least 15 mmHg. Left ventricular wall thicknesses cavity size normal. severe global left ventricular hypokinesis. basal inferolateral wall contracts best (LVEF = 25%). right ventricular cavity moderately dilated severe global free wall hypokinesis. [Intrinisic right ventricular systolic function depressed given severity tricuspid regurgitation.] abnormal septal motion/position consistent right ventricular pressure/volume overload. aortic valve leaflets mildly thickened (?#). aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. Mild (1+) mitral regurgitation seen. Moderate severe [3+] tricuspid regurgitation seen. pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size extensive systolic dysfunction c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Marked right ventricular cavity dilation free wall hypokinesis abnormal septal motion c/w marked pulmonary artery hypertension (not quantified). Moderate severe tricuspid regurgitation. Mild mitral regurgitation. Compared prior study (images reviewed) [2178-10-16], biventricular systolic function deteriorated heart rate much higher. Biventricular cavity size similar. Brief Hospital Course: 62F hx severe pulm HTN, CAD s/p DES Lcx/LAD [10/2177], prior CVA s/p b/l CEA's, PVD, [Hospital 2182] transferred OSH evaluation management right-sided diastolic CHF exacerbation background severe pulmonary hypertension rapidly decompensated passed away despite maximal medical therapy. . ACTIVE DIAGNOSES: . # Right-sided Diastolic CHF Exacerbation: Pt clinical evidence rales halfway lung fields, JVD, peripheral edema admission CXR evidence pulmonary edema BNP 11,000 OSH, ECHO demonstrating fluid overloaded RV S3 gallop exam. ruled ACS OSH negative enzymes non-ischemic EKG's transferred dopamine drip pressure support max O2 venturi mask moderate respiratory distress satting low 90's. arrival CCU, R IJ placed without complications started sildenafil 20mg QID hope pressor support vasodilatation pulmonary vasculature would increase cardiac output allow gentle diuresis. Unfortunately found anuric despite measures Cr 1.8 transfer 0.8-0.9 days prior OSH. late morning day following transfer, dobutamine added attempt improve ionotropy medication started BP began drop next hours norepinephrine added maintain MAPs >65. medications titrated try achieve stable blood pressure kept ranging 70/40-140/50. stability could reached. time HR 100-130's. CCU team (including CCU attending) attempted place arterial line better BP monitoring given severe peripheral vascular disease unsuccesful via radial aproach. Anesthesia contact[Name (NI) ] attempt axial arterial line deemed feasible. anesthesia attending attempted obtain L femoral arterial line without success. right side attempted given previous Fem-[Doctor Last Name ] bypass. oxygenation worsening switched 100% non-rebreather. around 1600 dobutamine stopped felt contributing persistently low BP's. remained stable around 2100 BP began decrease. 250 mL NS bolus given without response phenylephrine started point. Also around time oxygen saturation began drop BiPAP started. point patient dopamine, norepinephrine phenylephrine BP support BiPAP respiratory support BP 79/55-101/57 O2 sat 90%. 2300 (after ~3 hrs BiPAP) given tenious state persistently low BP, persistnently low O2 sat tachypnea discussion held patient family regarding endotracheal intubation. Given worseining cardiopulmonary status CCU team recommended intubation try achieve better oxygenation, prevent respiratory colapse allow us manage worsening heart failure maintaing patent airway adequate oxygenation. Anesthesia called 0000 non-emergent intubation. performed succesfully patient tolerated well. ~0030, milrinone added attempt improve ionotropy. point anesthesia attending asked assistance placing arterial line given need better blood pressure oxygenation parameters. Right radial attempted well left femoral without success. around 0100-0130 BP began drop, milrinone stopped vasopressin added. Despite 4 pressors BP continued drop. point given 4 amps bicarb, 1 mg epinephrine 1 amp calcium carbonate. family updated condition. Despite additions BP continued drop point bicarb drip epinephrine drip started. stabilized around 0200 remained HR 120-130's SBP 80-100's next several hours. around 0500 ventilator began alarming due high peak/plateau pressures. thought due pulmonary edema repeated succitioning brought frothy fluid. continued max doses 5 pressors throughout day maximal respiratory settings sake oxygenation. condition continued deteriorate despite maximal medical support. family made aware grave circumstances started carefully consider code status. coded later morning 2 days following transfer pulseless electrical activity coded briefly resuscitative efforts halted per family request. cause rapid decline unclear hypothesis team included possibly PE (with suboptimal LENI negative). abdominal ultrasound look possible ruptured AAA given report acute onset low back pain OSH negative. . # Anuric Acute Kidney Injury: Cr 1.8 admission oliguria/near anuria, 0.6-0.7 baseline. 0.9 yesterday OSH making urine. Thought due brief hypotensive episode receiving bolus 40mg IV lasix OSH. # Severe Chronic Pulmonary Hypertension/Cor Pulmonale: Unclear etiology. Perhaps related mild-moderate COPD CT (although re-assuring spirometry records) possibly recurrent embolic phenomena. treated aggressively unfortunately poor outcome. . CHRONIC DIAGNOSES: . # COPD/Hypoxia: PT mild-moderate COPD changes recent CT chest essentially normal PFT's. requires 3LNC home often worn sleep recently day even rest. 20-40 pack-year smoking history. home COPD medications. ended ventilated respiratory support above. . # CAD: Pt severe 3VD prior [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 LCx LAD 8/[2177]. Non-ischemic EKG admission OSH. Enzymes unimpressive x 3. chest pain discomfort. continued aspirin, plavix, statin. . # HLD: Stable. Continued statin. . # Severe PVD: Stable. Continued statin. . # NIDDM Complicated Neuropathy: Stable. Managed HISS in-house well lyrica gabapentin prior hemodynamic compromise. . TRANSITIONAL ISSUES: -To deep regret CCU team, Mrs. [Known lastname ] poorly hospital course. team took solace fact surrounded large, loving family hopefully felt little pain suffering final hours. Medications Admission: - Plavix 75mg PO daily - Gabapentin 200mg PO QHS - Aspirin 81mg PO daily - Metoprolol succinate 100mg PO daily - Ativan 1mg PO TID PRN - Metformin 100mg PO BID - Glyburide 2.5mg PO daily - Lisinopril 2.5mg PO daily - Torsemide 40mg PO daily - Lyrica 100mg PO BID - Tylenol PM 1 tab QHS - Simvastatin 40mg PO daily - Prilosec 20mg PO daily - Niacin 500mg PO BID Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: -Severe Pulmonary Hypertension/Cor Pulmonale -Biventricular diastolic congestive heart failure -Severe peripheral vascular disease -Chronic obstructive pulmonary disease Discharge Condition: Deceased Discharge Instructions: Patient transferred OSH acute decompensated biventricular heart failure complicated severe pulmonary hypertension. managed aggressively pressors (5 max doses) goal optimize cardiac function hope inducing diuresis. Unfortunately hemodynamics declined rapidly. Code called PEA initiation chest compressions epi x 1 time code called per family preference. Followup Instructions: N/A Completed by:[2178-12-28]	[ "5849", "4280" ]
Admission Date: [2181-4-20] Discharge Date: [2181-4-22] Date Birth: [2135-4-5] Sex: Service: MEDICINE Allergies: Drug Allergy Information File Attending:[First Name3 (LF) 23197] Chief Complaint: intoxication / seizure Major Surgical Invasive Procedure: Intubation History Present Illness: 46 y/o hx etoh abuse (per ED signout) possible depression presented emergency room around 6pm evening. obviously intoxicated. found EMS front liquor store brought eval. Initial vitals 98.1, p 100, bp 112/94, r 20, 95% RA. ED, climbed side rails bed fell. transferred Red Zone fall found mostly non-responsive despite noxious stimuli. CT scan head C-spine time negative. EJ femoral line place. almost intubated became arousable. . next hours, alert interactive. speech slurred appeared drunk. interview exam, patient complaining abdominal pain, bloody vomit stool (was guiac negative), suicidal ideation. fight brother-in-law feeling depressed that. also claimed wanted hurt brother-in-law, too. Psych consulted SI/HI waiting interview sober. . yellow zone waiting evaluation, abrupt onset fall went ground unresponsive minute two. witnessed tonic-clonic seizure. received 2 mg ativan time. Several minutes later another tonic-clonic seizure, given 2 mg ativan. intubated time airway protection. initially started midazolam gtt aggitated. switched propofol gtt. another CT head C-spine preliminarily read normal. . arrival floor, intubated sedated. moving 4 extremities would follow commands appropriately. . Past Medical History: ETOH abuse Hx pancreatitis Depression Social History: smokes occasionally, drinks heavily daily basis, also history ?heroin v. cocaine use [Male First Name (un) 1056] (moved 2 months ago), unmarried Family History: per brother-in-law, HTN Physical Exam: Vitals - afebrile, 141/96, 81, 18, 100% cmv 18 x 550, 100% x5 Gen - thin man, intubated, sedated, intermittently aggitated trying pull restraints HEENT - PERRLA, ET tube place CV - RRR, m,r,g Lungs - CTA B, referred vent sounds Abd - soft, NT, ND, hsm masses Ext - warm, well perfused, palp pulses, track marks; LE scarring Neuro - could obtain secondary infection Pertinent Results: [2181-4-20] 07:30PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2181-4-20] 07:30PM LIPASE-78* [2181-4-20] 07:30PM cTropnT-<0.01 [2181-4-20] 07:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-182 ALK PHOS-64 TOT BILI-0.1 [2181-4-20] 07:30PM WBC-6.3 RBC-5.35 HGB-15.1 HCT-46.1 MCV-86 MCH-28.1 MCHC-32.7 RDW-14.4 CT C-SPINE W/O CONTRAST Study Date [2181-4-21] 1:05 IMPRESSION: evidence acute injury cervical spine. Head CT NON-CONTRAST HEAD CT: intracranial hemorrhage, mass effect, [Doctor Last Name 352]-white matter differentiation, abnormality. ventricles extra-axial spaces within normal limits. evidence fracture. Mucosal thickening within bilateral maxillary sinuses ethmoid sinus air cells sphenoid sinuses mild. aerosolized secretions nasopharynx. IMPRESSION: acute intracranial abnormality. Brief Hospital Course: 46 y/o hx etoh abuse (per ED reports), coming intoxicated complaining abdominal pain, n/v/diarrhea, suicidal ideation. seizure intubated airway protection. . # Seizure: seizure activity initial one ED. [Month (only) 116] due EtOH intoxication. CT head, labs unremarkable. . # Abdominal Pain: Resolved pt extubated. . # Respiratory Failure: pt intubated altered mental status airway protection setting seizure. successfully extubated morning following admission, respiratory problems. . # EtOH/SI: pt seen psychiatry found capacity make medical decisions. declined rehab/detox reported psychiatric follow [Hospital1 ] CHC Tuesday. pt discharged care girlfriend planned take church stay overnight. Medications Admission: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice day. 2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO bedtime. Discharge Medications: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice day. 2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO bedtime. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Intoxication Discharge Condition: Mental Status: Clear coherent, fluent Spanish Level Consciousness: Alert interactive Activity Status: Ambulatory - Independent Discharge Instructions: admitted intoxication. intubated (a breathing tube placed) protect airway. evaluated psychiatry, felt safe return home family, close psychiatric follow up. . Please continue take seroquel wellbutrin. added folate thiamine nutritional status. Followup Instructions: Please follow psychiatrist [Hospital1 ] St. Community Health Center planned Tuesday.	[ "4019" ]
Admission Date: [2147-6-8] Discharge Date: [2147-6-12] Date Birth: [2088-3-18] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 689] Chief Complaint: polyuria, polydipsia Major Surgical Invasive Procedure: None History Present Illness: 59M HTN, glaucoma presents polyuria polydipia. regular health status 3 weeks prior admission, started note polyuria, polydipsia, altered taste eating. dryness mouth got worsen chewing food eventually tasted food like "cardboard". could swallow food "it stayed mouth". stated could sense recognize sweetness, salt taste, bitter taste sour taste food. denies f/c/n/v, dysuria, cough, diarrhea. . ED, vitals showed 96.0 HR 90, reg BP 177-193/96 RR 23 SO2 96% r/a. noted ARF creatinine 1.8 hyperglycemia sugar 360, AG 22, positive urine ketones. started insulin gtt, given 3L NS, admitted MICU care. Past Medical History: 1. Hypertension 2. Glaucoma Social History: Married, lives wife, daughter. [Name (NI) 1403] Pharmaceutical company drug development. Occasional ETOH, Smoke [12-20] cigarette/day now, used smoke 10-15years, Denied drug. Family History: Mother diabetes stroke. Father died patient 20 years, sure cause. Physical Exam: vitals: 97.9 78 174/70 17 97 RA gen: awake, alert, NAD heent: perrl, eomi, mmm cv: RRR, m/r/g pulm: CTAB abd: soft, NT/ND ext: 1+ DP pulses, edema neuro: a+ox4. CN ii-xii intact, moves extremities well. Pertinent Results: [2147-6-8] - Admission labs WBC-5.5 RBC-5.39 Hgb-17.0 Hct-50.8 MCV-94 MCH-31.5 MCHC-33.4 RDW-13.5 Plt Ct-186 Glucose-360* UreaN-12 Creat-1.8* Na-129* K-6.6* Cl-95* HCO3-11* AnGap-30* Albumin-4.7 Calcium-9.4 Phos-2.9 Mg-2.6 %HbA1c-13.7* tox screen: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG. . [2147-6-9] Triglyc-176* HDL-34 CHOL/HD-7.3 LDLcalc-179* Homocys-7.1 . [2147-6-12] WBC-4.2 RBC-4.10* Hgb-13.3* Hct-37.2* MCV-91 MCH-32.4* MCHC-35.7* RDW-14.0 Plt Ct-118* Glucose-219* UreaN-4* Creat-1.2 Na-136 K-3.4 Cl-102 HCO3-21* AnGap-16 Phos-2.4* Mg-2.3 . [2147-6-8] CT HEAD WITHOUT CONTRAST: intracranial mass lesion, hydrocephalus, shift normally midline structures, minor major vascular territorial infarct apparent. Density values brain parenchyma within normal limits. surrounding osseous soft tissue structures unremarkable. Falx calcifications noted. visualized paranasal sinuses unremarkable. IMPRESSION: acute intracranial pathology, including sign intracranial hemorrhage. . [2147-6-8] PA LATERAL VIEWS CHEST: cardiac silhouette, mediastinal hilar contours normal. 8-mm nodule right lung base. Otherwise, lungs clear. evidence pleural effusions. evidence pneumothorax. pulmonary vasculature normal. IMPRESSION: 8-mm lung nodule right lung base. Comparison prior outside studies, feasible, follow-up study recommended assess stability. . [2147-6-9] CT CHEST W/O CONTRAST FINDINGS: Linear scarring atelectasis present within right lower lobe, evidence suspicious lung nodule mass region. suspicious endobronchial lesions identified. Small bulla present right upper lobe, minimal areas emphysema extreme lung apices. suspicious lytic blastic skeletal lesions identified. Degenerative changes present spine. Left lobe thyroid gland enlarged measuring 3.7 cm. enlarged mediastinal hilar lymph nodes present. Heart size normal. pericardial pleural effusion. imaged portion upper abdomen, probable mild fatty infiltration liver, relative sparing around gallbladder. Imaged portions adrenal glands remaining portion upper abdomen unremarkable, please note examination specifically tailored evaluating abdominal structures. IMPRESSION: 1. Linear scar versus atelectasis right lower lobe evidence discrete lung nodule mass. 2. Probable fatty infiltration liver. 3. Enlarged left lobe thyroid gland, probably representing asymmetric goiter, thyroid ultrasound may considered complete assessment warranted clinically. Brief Hospital Course: 59 AA HTN, glaucoma presents DKA ARF, without prior diagnosis diabetes. presentation consistent "flatbush" type 1B diabetes. . 1. Acute renal failure: Cr 1.8 admission. discharge, decreased 1.2 IVF. Unclear baseline. Likely prerenal setting DKA. . 2. DKA: Newly diagnosed DM2; given age race may represent Flatbush Phenomenon given mild DKA presentation. evidence cause anion gap acidosis, patient negative tox screen lactate significantly elevated. initially admitted ICU Insulin gtt; transitioned glargine 25 units daily Humalog SS. Received diabetes education [Last Name (un) ] consultants nurse educators, trained administer home insulin outpatient follup [Last Name (un) ]. BS well controlled regimen AG closed normal. HgA1c level sent 13.9%. ASA started admission given multiple cardiac risk factors CAD equivalent. . 3. HTN: Given new onset DMII, started ACE. BPs normal range. titrate needed outpatient. Patient evidence LVH ekg, likely hypertensive etiology. need pcp f/u. . 4. Lung nodule: Incidental lung nodule noted CXR follow Chest CT revealed Linear scar versus atelectasis right lower lobe evidence discrete lung nodule mass. . 5. High Cholesterol cholesterol panel showed elevated levels (TC 248, LDL 179). started simvastatin 20mg daily. . 6. Glaucoma continued pilocarpine 0.5% 1 gtt eyes q6h . 7. Incidental L Thyroid Lobe enlargement probably represents asymmetric goiter, thyroid ultrasound may considered complete outpatient assessment warranted clinically. . 8. Altered Taste Neurology consulted, felt necessary inpatient assessment time. Suggest Diamox cause, known appetite loss alter sensation taste. follow outpatient. . FEN: diabetic diet . Proph: heparin SC . Access: PIVs . full code Medications Admission: 1. Pilocarpine 2. Diamox 3. Kossup Discharge Medications: 1. Pilocarpine HCl 0.5 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once day (at bedtime)). Disp:30 Tablet(s) Refills:0 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:0 5. Insulin Glargine 100 unit/mL Solution Sig: One (1) 25 Subcutaneous every morning breakfast. Disp:1 vial Refills:2 6. Humalog 100 unit/mL Solution Sig: One (1) see sliding scale Subcutaneous qAC HS. Disp:1 vial Refills:2 7. Syringe Needle, Safety 1 mL 28 X [12-20] Syringe Sig: Four (4) Miscellaneous day. Disp:120 syringes Refills:2 8. sharps box Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetes Mellitus II ketoacidosis . Secondary: Hypertension Glaucoma Discharge Condition: Improved, stable Discharge Instructions: Please take medications, including insulin, prescribed. Please check blood sugar home instructed. experience symptoms concerning you, including dizziness/lightheadedness, fatigue/lethargy, excessive urination/thirst, please call PCP go nearest Emergency Room. Followup Instructions: Please follow PCP [Last Name (NamePattern4) ] [12-20] weeks. Also, please call [Last Name (un) ] Center make appointment diabetes care management.	[ "5849", "4019" ]
Admission Date: [2129-3-4] Discharge Date: [2129-3-6] Date Birth: [2053-6-30] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Ace Inhibitors Attending:[First Name3 (LF) 443] Chief Complaint: RCA dissection Major Surgical Invasive Procedure: Cardiac Catheterization placement 4 bare metal stents Intra-operative (catheterization) trans-esophageal echocardiogram History Present Illness: 75 y/oF hypertension, HL exertional angina initially presented elective cardiac catheterization c/b RCA dissection, transferred CCU management. . Briefly, patient complained exertional angina several weeks. described chest discomfort radiating jaw walking treadmill riding exercise bike vigorously. Also experianced dyspnea chest discomfort walking 1 flight stairs. Symptoms always resolved rest. Exercise stress test [2129-2-14] concerning ischemia: 8 minutes [Doctor First Name ] protocol, peak HR 116 (80% predicted age), patient developed recurrent angina EKG showing 0.5mm ST depressions infero-lateral leads. Given positive stress test, patient referred elective coronary catheterization. . morning, underwent coronary catheterization showed calcification coronary arteries diffuse disease RCA proximal 90% stenosis distal 60-80% stenosis. catheterization complicated RCA dissection retrograde extention right sinus valsalva. received four bare metal stent RCA: 2 overlapping distal, 1 non-overlapping proximal, 1 ostial integrity stents. Following ostial stent depolyment, contrast longer seen flowing sinus. Post-catheterization TEE showed unchanged AI, functioning leaflets pericadial effusion. transfered CCU stable condition. . arrival CCU, endorsed mild left sided chest jaw pain significantly improved compared experienced cath lab. endorsed comfortably breathing denied complaints. . review systems, denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. denies recent fevers, chills rigors. denies exertional buttock calf pain. review systems negative. . Cardiac review systems notable chest pain per HPI; denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - moderate AI, moderate MR 3. PAST MEDICAL HISTORY: - Left Breast Cancer s/p Mastectomy [2103] - GERD - Hemorrhoids - Pneumonia x2 (in [2097]'s) - Hiatial Hernia - S/p Hysterectomy - Osteopenia - s/p Tonsillectomy - s/p Adenoidectomy - s/p Appendectomy Social History: Retired, lives husband. [Name (NI) ] active lifestyle, going gym daily - Tobacco history: - ETOH: drinks approx 4oz red wine daily - Illicit drugs: denies Family History: - family history early MI, arrhythmia, cardiomyopathies, sudden cardiac death; otherwise non-contributory. - Mother: died age 83 CHF - Father: died 80s CVA Physical Exam: Admission Exam: VS: T=98.4 BP=127/80 HR=93 RR=14 O2 sat=100% 2L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP 8cm. CARDIAC: PMI located 5th intercostal space, midclavicular line. RR, systolic murmur loudest apex. thrills, lifts. LUNGS: left mastectomy scar noted. Resp unlabored, accessory muscle use. CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: c/c/e. femoral bruits. SKIN: stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge Exam: Tc 98.0, Tm 98.4, BP 128-146/49-68, HR 58-88, RR 16-18, Sats 95-99% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP 8cm. CARDIAC: PMI located 5th intercostal space, midclavicular line. RR, systolic murmur loudest apex. thrills, lifts. LUNGS: CTAB ABDOMEN: Soft, NTND. HSM tenderness. EXTREMITIES: c/c/e. femoral bruits. 2+ pulses radial/DP Pertinent Results: Admission Labs ([2129-3-4]): Hct-32.2* Glucose-218* UreaN-17 Creat-0.6 Na-134 K-3.8 Cl-99 HCO3-23 AnGap-16 Calcium-9.5 Phos-3.7 Mg-2.1 [2129-3-4] 04:09PM BLOOD CK(CPK)-69 [2129-3-5] 06:00AM BLOOD CK(CPK)-98 [2129-3-4] 04:09PM BLOOD CK-MB-4 cTropnT-<0.01 [2129-3-5] 06:00AM BLOOD CK-MB-5 cTropnT-LESS . Imaging: Intra-operative TEE ([2129-3-4]): Conclusions atrial septal defect seen 2D color Doppler. left ventricle well seen overall left ventricular systolic function normal (LVEF>55%). simple atheroma aortic arch. mobile density seen aortic sinus right coronary cusp consistent intimal flap/aortic dissection.the flap extends minimally sinus Valsalva.The aortic valve leaflets (3) mildly thickened. Mild moderate ([12-12]+) aortic regurgitation seen. Moderate (2+) mitral regurgitation seen. pericardial effusion. IMPRESSION: Dissection flap right coronary sinus, largely contained within sinus Valsalva. Preserved global LV systolic function mild moderate aortic regurgitation moderate mitral regurgitation. . CTA chest ([2129-3-4]): FINDINGS: Trace pericardial sluid noted. multivessel coronary arterial calcification mitral annular calcifications. Density right coronary artery compatible known stent. proximal RCA appears low attenuation centrally, assessment limited overlying stent non-gated study. Close origin RCA, minimal linear mural irregularity proximal aorta seen (4,58), likely represents small focal dissection noted time coronary angiogram. distal propagation seen. calcification left anterolateral papillary muscles noted (6,61). likely due prior ischemia. pulmonary arterial tree opacified without evidence pulmonary embolism. mediastinal, hilar, axillary lymphadenopathy CT size criteria. exception trace bibasilar dependent atelectases , lungs clear. Central airways remain patent. Limited subdiaphragmatic evaluation demonstrates hyperdense material within gallbladder, compatible vicarious excretion contrast status post recent cardiac catheterization. tiny hiatal hernia may present. left adrenal gland mildly prominent, without focal nodularity. small non-specific 7mm hypodensity seen dome right hepatic lobe (4,68), small characterize. BONE WINDOW: focal concerning lesion. Mild multilevel thoracic spondylosis present. Mild levoconvex thoracic curvature noted. IMPRESSION: 1. Tiny linear irregularity aortic root adjacent RCA origin compatible known tiny dissection. propagation seen. 2. Apparent opacification RCA proximally may artifactual related stent non-gated study, clinical correlation advised. 3. Coronary calcification small area calcification tip anterolateral papillary muscle. . Cardiac Cath ([2129-3-4]): Report yet finalized . Discharge Labs: [2129-3-6] 08:35AM BLOOD WBC-7.2 RBC-3.77* Hgb-11.8* Hct-32.7* MCV-87 MCH-31.2 MCHC-36.0* RDW-12.6 Plt Ct-299 [2129-3-6] 08:35AM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-137 K-4.0 Cl-102 HCO3-24 AnGap-15 [2129-3-6] 08:35AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0 Brief Hospital Course: ASSESSMENT PLAN Mrs. [Known lastname ] 75 year-old woman HTN, HLD exertional angina s/p elective cardiac catheterization c/b RCA dissection placement 4 BMS RCA. # Coronaries: Patient known CAD identified cardiac cath [3-4] s/p RCA dissection cardiac catheterization placement 4 BMS RCA. Patient received integrillin procedure. Chest pain significantly improved. Discussed patient importance avoiding valsalva manuvers increase intra-thoracic pressure. CTA report finalized per radiology wet read significant dissection still noted post-proceedure although contrast timing sub-optimal evaluation. CTA pt received premedication benadryl, prednisone, mucomyst/IV hydration. Nitro gtt weaned cardiac enzymes stable. Pt continued ASA indefinitely need take plavix 75 mg daily least 1 month. Plan repeat CTA 2-3 weeks discharge re-evaluate RCA dissection. Pt follow-up Dr. [Last Name (STitle) ] outpatient setting. # Pump: Patient know CHF symptoms. LVEF obtained durring TEE performed cath lab. Patient remained hemodynamically stable hospitalization. # RHYTHM: Patient sinus rhythm. known dysrhythmia. monitored Tele CCU floor signficiant arrhythmias noted. # HTN: Patient Hx HTN metoprolol home BP med. Day cath pt started 25mg daily losartan better BP control metoprolol increased 50 mg po tid 200 mg po daily. # HLD: Patient takes rosuvastatin 20mg daily home atorvastatin 80mg admitted. discharged home regimen rosuvastatin 20 mg po daily. #Code: Full (confirmed patient) Medications Admission: - ciprofloxacin 250 mg [Hospital1 ] prn UTI - hydrocortisone acetate - 25 mg Suppository - 1 rectally tid prn irritation pressure - metoprolol tartrate 50mg [Hospital1 ] - omeprazole 20 mg Capsule, Delayed Release(E.C.) daily - rosuvostatin 20 mg daily - vitamin C 500 mg daily - ASA 81 mg daily - calcium carbonate- vitamin D3 500 mg (1,250 mg)-400 U Tablet daily - geriatric MVI w/iron 1tab daily - magnesium 250mg 4 tabs daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO day. 7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO day. 8. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO day. 9. geriatric multivit w/iron-min Tablet Sig: One (1) Tablet PO day. 10. magnesium 250 mg Tablet Sig: Four (4) Tablet PO day. 11. hydrocortisone acetate 25 mg Suppository Sig: One (1) Rectal day needed irritation pressure . Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Coronary artery disease Coronary artery dissection Secondary: Hypertension Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted hospital small tear one coronary arteries occurred cardiac catheterization. help stabilize artery open coronaries found narrowings, 4 bare metal stents placed coronary arteries. chest pain improved significantly next day CT scan chest showed worsening tear artery. started plavix 75 mg daily Aspirin 325 mg daily. must take plavix every day least next month take aspirin daily indefinitely order help keep stents clotting. important take medications every day otherwise risk clots forming stents. also increased metoprolol dose started new blood pressure medication called losartan help keep blood pressure good range. follow-up Dr. [Last Name (STitle) ] likely get repeat CT scan heart [1-13] weeks. following changes made medications: - Metoprolol dose increased metoprolol XL 200 mg mouth daily - Added Losartan 25 mg mouth daily blood pressure - Added clopidogrel (Plavix) 75mg mouth daily least next month - important miss [First Name (Titles) 691] [Last Name (Titles) 11014]s medication. Please talk Dr. [Last Name (STitle) ] ok stop taking medication. - Increased Aspirin dose 81 mg daily 325mg mouth daily - Continue home medications refrain lifting weights greater 20 pounds 1 month hospital discharge. Followup Instructions: Follow-up Dr. [Last Name (STitle) ] [12-12] weeks. Please call office make sure appointment. number call [Telephone/Fax (1) 4105]. likely repeat CT scan heart [1-13] weeks. refrain lifting weights greater 20 pounds 1 month hospital discharge.	[ "4019", "2720" ]
Admission Date: [2192-1-5] Discharge Date: [2192-1-20] Date Birth: [2117-9-11] Sex: F Service: CARDIOTHORACIC Allergies: Hydralazine / Opioid Analgesics / Compazine Attending:[First Name3 (LF) 922] Chief Complaint: chest pain / epigastric pain Major Surgical Invasive Procedure: Coronary artery bypass grafts x 4 (LIMA-LAD,SV-DG,SV-OM,SV-PDA) [1-13] left heart catheterization, coronary angiography History Present Illness: patient 74 year-old female significant PMH recent NSTEMI ([2191-11-5]), CAD, hyperlipidemia, hypertension, DM-2, ESRD hemodialysis presented several hours epigastric pain evolved predominant complaint [2193-8-13] chest pressure. similar presentation [2191-11-22] diagnosed NSTEMI positive cardiac enzymes noted new LBBB EKG. underwent cardiac catheterization time showed LAD lesion 90% totally occluded mid LAD lesion, RCA lesion 90%, circumflex showed minimal disease. Unfortunately, unsuccessful PCI, CT Surgery consulted arrange future CABG plan. Past Medical History: -Hypothyroidism (thyroidectomy [2173] benign growth) -Diabetes type II >10yrs -End-Stage Renal Disease: hemodialysis left forearm AV graft [2187], using Tunelled HD Line -CVA [2186]: left caudate infarct; several mini-strokes -Gait disorder/shaky unsteady walks -Splenectomy [2145] (trauma related) -SVC stenosis -Cataract surgery (bilateral) -Hypertension -Hyperlipidemia -Coronary Artery Disease (recent cath [11/2191] showing 90% proximal LAD totally occluded mid LAD 90% RCA minimal disease circumflex) Social History: Patient lives alone home daughter [Name (NI) ]([Telephone/Fax (1) 108910]) extensively involved care. 7 children. uses walker baseline, wheelchair bound 1 year per daughter patient afraid falling. denies current past tobacco, alcohol illicit drug use. Family History: Mother: died 5 year ago (cause unknown pt) Father: died pt 17 (cause unknown pt) Children major medical problems Physical Exam: Admission VS -T 98.6F, BP 153/100, HR 80s, RR 20, 96% 3L oxygen Gen: appears fatigued, middle aged female NAD, Oriented x3. Affect somewhat flattened. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. Neck: Supple JVP 7-8cm. Left EJ place (clean/intact) left IJ HD catheter place non-erythematous surrounding skin. CV: S1/S2 appreciated, RRR, II-III/VI systolic murmur noted @ LUSB, murmurs, rubs, gallops. thrills, lifts. S3/S4. Chest: chest wall deformities scoliosis, + Mild kyphosis. Respirations unlabored, accessory muscle use. Decreased aeration bases bilaterally (R>L). wheezes rhonchi. Abd: Soft, mild upper epigastric tenderness, moderate distension. HSM tenderness RUQ. Due distension, unable ausculate well abdominial bruits -but 4 quadrants +normoactive BS. Ext: [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] cool, 1+ DP PT pulses left 2+ DP 1+ PT pulse right. femoral bruits/femoral pulses 2+ bilaterally. Skin: LE calves scaling skin, sores/lesions/rashes. Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ . Discharge VS 98.4 BP 144/71 HR 80 SR RR 20 O2sat 97%-2LNP Gen NAD, sitting chair Neuro A&O x3, nonfocal exam Pulm CTA bilat CV RRR, sternum stable, incision CDI Abdm soft, NT/+BS Ext Warm, trace pedal edema bilat. Skin staples L groin thigh. Left subclav HD catheter Pertinent Results: ADMISSION LABS: [2192-1-5] 03:57PM PT-41.6* PTT-37.8* INR(PT)-4.6* [2192-1-5] 03:03PM GLUCOSE-381* NA+-138 K+-4.4 CL--91* TCO2-27 [2192-1-5] 03:03PM HGB-14.3 calcHCT-43 [2192-1-5] 02:45PM GLUCOSE-385* UREA N-33* CREAT-4.2* SODIUM-137 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-27 ANION GAP-23* [2192-1-5] 02:45PM ALT(SGPT)-150* AST(SGOT)-104* CK(CPK)-46 ALK PHOS-205* TOT BILI-0.3 [2192-1-5] 02:45PM LIPASE-50 [2192-1-5] 02:45PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.2 [2192-1-5] 02:45PM WBC-14.1* RBC-4.46 HGB-13.8 HCT-44.2 MCV-99* MCH-31.0 MCHC-31.3 RDW-17.4* [2192-1-5] 02:45PM BLOOD cTropnT-0.21* [2192-1-6] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.29* [2192-1-6] 12:19AM BLOOD CK(CPK)-77 [2192-1-5] 02:45PM BLOOD CK(CPK)-46 [2192-1-19] 09:30AM BLOOD WBC-17.8* RBC-3.11* Hgb-9.6* Hct-30.0* MCV-97 MCH-30.8 MCHC-32.0 RDW-17.8* Plt Ct-280 [2192-1-19] 09:30AM BLOOD Plt Ct-280 [2192-1-17] 04:00AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3* [2192-1-19] 09:30AM BLOOD Glucose-233* UreaN-43* Creat-5.2# Na-137 K-5.1 Cl-99 HCO3-28 AnGap-15 [2192-1-12] 09:00AM BLOOD %HbA1c-7.0 [2192-1-6] 01:10PM BLOOD TSH-2.9 . ADDITIONAL STUDIES: [2192-1-10] Cardiac MD/Thallium Viability study: IMPRESSION: 1. Moderate Anterior wall/apical defect completely reversible 24 h. 2. Moderate septal defect partially reversible 24 h. . [2192-1-8] CTA Chest/Pelvis/Abdomen : IMPRESSION: 1. opacification SMA, without evidence ischemic bowel. 2. Extensive atherosclerotic disease, without aortic aneurysm dissection seen. 3. Extensive colonic diverticulosis, minimal stranding surrounding descending colon, suggesting mild uncomplicated diverticulitis. 4. Incompletely characterized hypodense lesions kidneys noted. 5. Soft tissue nodule arising medial limb left adrenal gland incompletely characterized. 6. Increased number mediastinal retroperitoneal lymph nodes, without size enlargement. =============================================================== [Known lastname ],[Known firstname 108974] [Medical Record Number 108975] F 74 [2117-9-11] Radiology Report CHEST (PA & LAT) Study Date [2192-1-19] 4:15 PM [Hospital 93] MEDICAL CONDITION: 74 year old woman s/p CABG x4 REASON EXAMINATION: atelectasis Final Report HISTORY: Status post CABG atelectasis. FINDINGS: comparison study [1-17], little overall change. Extensive opacification left base persists, possibly increasing pleural fluid. Central catheter remains place. right axillary catheter remains outside hemithorax. DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Approved: [First Name8 (NamePattern2) ] [2192-1-19] 6:21 PM = = = = = = = = ================================================================ [Known lastname ],[Known firstname 108974] [Medical Record Number 108975] F 74 [2117-9-11] Radiology Report [Numeric Identifier ] PICC W/O PORT Study Date [2192-1-17] 12:30 PM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2192-1-17] SCHED PICC LINE PLACMENT SCH Clip # [Clip Number (Radiology) 108976] Reason: ESRD HD. LT scv Permacath, s/p mult RIJ caths. Unable [Hospital 93] MEDICAL CONDITION: 74 year old woman s/p cabg REASON EXAMINATION: ESRD HD. LT scv Permacath, s/p mult RIJ caths. Unable pass wire IJs time recent CABG. RT femoral Cordis. IV unable thread wire PICC bedside. please place midline *** Final Report INDICATION: 74 year old woman requiring IV access. Request right mid-line due presence left HD catheter SVC. procedure explained patient. timeout performed. RADIOLOGIST: Dr. [Last Name (STitle) 3012] Dr. [First Name (STitle) ] performed procedure. Dr. [Last Name (STitle) 2492], attending radiologist, present supervised procedure. TECHNIQUE: Using sterile technique local anesthesia, right brachial vein punctured direct ultrasound guidance using micropuncture set. Ultrasound images obtained immediately establishing intravenous access. guidewire advanced right subclavian vein fluoroscopic guidance. peel- away sheath placed guidewire double-lumen PICC measuring 20 cm length placed peel- away sheath tip positioned axillary vein fluoroscopic guidance. Position catheter confirmed fluoroscopic spot film chest. peel-away sheath guidewire removed. catheter secured skin, flushed, sterile dressing applied. patient tolerated procedure well. immediate complications. IMPRESSION: Uncomplicated ultrasound fluoroscopically guided double-lumen PICC placement via right brachial venous approach. Final internal length 20 cm, tip positioned right axillary vein. line ready use. study report reviewed staff radiologist. DR. [First Name (STitle) 2671] [Doctor Last Name ] DR. [First Name8 (NamePattern2) 95] [Last Name (NamePattern1) ] DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Approved: WED [2192-1-18] 9:17 = = = = = ================================================================ [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 108974] [Hospital1 18] [Numeric Identifier 108977] (Complete) Done [2192-1-13] 6:17:28 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2117-9-11] Age (years): 74 F Hgt (in): 60 BP (mm Hg): / Wgt (lb): 140 HR (bpm): BSA (m2): 1.61 m2 Indication: Intraop CABG evaluate LV function, Valvular function, Aortic contours ICD-9 Codes: 410.92, 440.0, 424.0 Test Information Date/Time: [2192-1-13] 18:17 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3319], MD Doppler: Full Doppler color Doppler Test Location: Anesthesia West cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: [Doctor Last Name *] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 6.3 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 25% 30% >= 55% Aorta - Ascending: 3.5 cm <= 3.4 cm Findings LEFT ATRIUM: Marked LA enlargement. mass/thrombus [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. ASD 2D color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Severe regional LV systolic dysfunction. RIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal RV systolic function. AORTA: Mildly dilated ascending aorta. Focal calcifications ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. MS. Moderate severe (3+) MR. [First Name (Titles) ] vena contracta >=0.7cm TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve well seen. Physiologic (normal) PR. Dilated main PA. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, = Akinetic, = Dyskinetic Conclusions Pre Bypass: left atrium markedly dilated. mass/thrombus seen left atrium left atrial appendage. atrial septal defect seen 2D color Doppler. mild symmetric left ventricular hypertrophy. left ventricular cavity size top normal/borderline dilated. severe regional left ventricular systolic dysfunction septal hypokinesis base akinesis mid apical levels, hypokinesis anteroseptal anterior walls.. right ventricular cavity moderately dilated borderline normal free wall function. ascending aorta mildly dilated. complex (>4mm) atheroma aortic arch. descending thoracic aorta mildly dilated. complex (>4mm) atheroma descending thoracic aorta. aortic valve leaflets (3) mildly thickened. aortic valve stenosis. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. Moderate severe (3+) central mitral regurgitation seen. mitral regurgitation vena contracta >=0.7cm. small pericardial effusion. TEE used hemodynamic monitoring throughout. Estimated PASP 43 pre bypass. Frequent cardiac output measurements obtained. CO 2.0 start case, increased 2.7, later 3.9 prior bypass. Post Bypass: Patient epinepherine infusion (.08) phenylepherine (2), AV paced. Biventricular function slightly improved ionotropes. LVEF 30-35%. anterior wall motion improved. septum paced paradoxical movement cannot fully evaluated. Mitral reguritation [1-6]+. Aortic contours intact. Remaing exam unchanged. Cardiac output post bypass initally [2-7], improved end case 4.1 ionotropes volume. finidings discussed surgeons time exam. certify present procedure compliance HCFA regulations. Electronically signed [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2192-1-16] 14:34 Brief Hospital Course: Ms. [Known lastname 108904] 74 year old female past medical history recent NSTEMI ([11/2191]), extensive coronary artery disease, hyperatension, diabetes mellitis type II, end stage renal disease hemodialysis, presented emergency department several hours epigastric pain chest pressure. ruled acute coronary syndrome/myocardial infarction. workup mesenteric ischemia negative scheduled coronary artey bypass. [2192-1-13] underwent coronary artery bypass grafting times four. procedure performed Dr. [Last Name (STitle) 914]. tolerated procedure well transferred critical stable condition surgical intensive care unit. post-operative day one dialyzed, extubated, weaned pressors. Dialysis resumed following day. chest tubes epicardial wires removed. seen consultation physical therapy service. next several days hospital course uneventful, progressed slowly physical activity POD7 decided ready discharge rehabilitation [Hospital1 ]. Medications Admission: -Vitamin B Complex/Vitamin C -Folic Acid 1 mg daily -Renagel 800 mg tablet three times day. -Levothyroxine 100 mcg tablet daily -Atorvastatin 80 mg Tablet PO daily -Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: 4,000-11,000 unit dwell Injection PRN (as needed) needed line flush: for use dialysis ONLY. -Prevacid 30 mg Capsule, (E.C.)daily. -Lorazepam 0.5 mg tablet PO Q6H needed Anxiety. -Acetaminophen 325 mg, 1-2 Tablets PO Q6H PRN -Warfarin 7.5 mg tablet PO daily 4 PM. -Aspirin 81 mg tablet day. -Lisinopril 40 mg tablet daily. -Toprol XL 100mg daily. . Discharge Medications: 1. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q4H (every 4 hours) needed. 4. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) needed constipation. 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-6] Drops Ophthalmic PRN (as needed). 6. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (2) ]: 5000 (5000) units Injection TID (3 times day). 7. Sevelamer Carbonate 800 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO TID W/MEALS (3 TIMES DAY MEALS). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Atorvastatin 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Last Name (STitle) ]: One (1) Cap PO DAILY (Daily). 11. Folic Acid 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 12. Lisinopril 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 13. Levothyroxine 50 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times day) needed. 15. Ibuprofen 600 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) needed pain. 16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [Last Name (STitle) ]: One (1) Appl Rectal QID (4 times day) needed. 17. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 1.5 Tablets PO TID (3 times day). 18. Glipizide 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times day). 19. Insulin Lispro 100 unit/mL Solution [Last Name (STitle) ]: sliding scale Subcutaneous Q AC&HS. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: unsatble angina s/p coronary artery bypass grafts end stage renal disease hypertension cerebrovascular disease noninsulin dependent diabetes mellitus hypothyroidism s/p thyroidectomy s/p hysterectomy s/p splenectomy Discharge Condition: good Discharge Instructions: shower daily, baths swimming lotions, creams powders incisions driving 4 weeks narcotics lifting 10 pounds 10 weeks report fever greater 100.5 report redness of, drainage incisions report weight gain greater 2 pounds day 5 pounds week take medications directed Followup Instructions: Dr. [Last Name (STitle) 914] 4 weeks ([Telephone/Fax (1) 170]) Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [1-6] weeks ([Telephone/Fax (1) 250]) Completed by:[2192-1-20**]	[ "4280", "2724" ]
Admission Date: [2140-2-29] Discharge Date: [2140-3-4] Date Birth: [2069-7-18] Sex: F Service: NEUROSURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: C2 type II dens fracture s/p HALO placement Major Surgical Invasive Procedure: [2140-2-29]: Open reduction internal fixation type II C2 dens fracture. History Present Illness: Pt 79 year old woman known C2 fracture sustained fall [2139-10-22]. placed halo time, discharged [Hospital 100] Rehab, today follow up. yet discharged rehabilitation. complains pain related halo times, feels decrease mobility especially getting bed chair. additional complaints. HA, numbness/tingling. Past Medical History: CAD Hiatal hernia SVD Vaginal hysterectomy Post colporrhaphy bladder neck suspension, R breast lumpectomy L mastectomy Breast Ca C2 type II dens fracture. Social History: widowed Family History: Father - CAD, [Name (NI) ] Ca. Mother - PE Physical Exam: GENERAL: alert oriented x 3, pleasant, acute distress. NEUROLOGIC: halo intact. able rise seat, tentative, uses arms additional strength. Full strength throughout, [3-25]. Deep tendon reflexes 2+ throughout. Sensation intact. Halo pin sites, erythema, edema, drainage. C-spine CT [2-2] - seen oblique fracture involving base odontoid process (type 2). Fracture fragments appear unchanged alignment. Multiple small osseous fragments, also unchanged appearance, noted. slight cortication still-evident fracture line margins. However, lack change alignment suggests development fibrous [Hospital1 ]. Pertinent Results: [2140-3-3] 06:45AM BLOOD WBC-8.9 RBC-4.32 Hgb-12.9 Hct-38.4 MCV-89 MCH-29.9 MCHC-33.6 RDW-14.0 Plt Ct-99* [2140-3-3] 06:45AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-145 K-4.3 Cl-105 HCO3-32 AnGap-12 [2140-3-3] 06:45AM BLOOD Calcium-8.5 Phos-2.8# Mg-1.8 RADIOLOGY Final Report CT C-SPINE W/O CONTRAST [2140-3-1] 12:03 PM CT C-SPINE W/O CONTRAST Reason: please evaluate post op 0800 [2140-3-1]. thank you. [Hospital 93] MEDICAL CONDITION: 70 year old woman s/p ORIF C2 type II dens fx. REASON EXAMINATION: please evaluate post op 0800 [2140-3-1]. thank you. CONTRAINDICATIONS IV CONTRAST: None. CT scan cervical spine multiplanar reformatted images. Exam compared previous examination [2140-2-2]. FINDINGS: intramedullary fixation fracture C2 odontoid metallic device extending body C2 odontoid process. evidence abnormal calcification within spinal canal. retropharyngeal mass demonstrated unchanged prior studies. alteration alignment. IMPRESSION: Status post internal fixation odontoid fracture. Stable appearance retropharyngeal mass. DR. [First Name (STitle) 23303] [Doctor Last Name ] Approved: TUE [2140-3-1] 3:57 PM Brief Hospital Course: Pt admitted neurosurgery service s/p ORIF type II C2 dens fracture. Pt keep PACU overnight q1 hr neurochecks. Post operatively awake, alert orientated X3 moving upper extremeties good strength. post op CT scan: FINDINGS: intramedullary fixation fracture C2 odontoid metallic device extending body C2 odontoid process. evidence abnormal calcification within spinal canal. retropharyngeal mass demonstrated unchanged prior studies. alteration alignment. seen PT found hypotensive observed additional day. Social work also involved discharge planning Ms [Known lastname 98305] agreed return rehab. Medications Admission: protonix 40mg qd triethanolamine/water (shampoo) Th@10 scalp. neosporin triple antibiotic ointment pin sites tylenol 650 q4h prn tylenol 650 [Hospital1 ] fosamax 70mg qSat lipitor 80mg qPM dulcolax 10mg PR prn calcium/vit 500 tid celexa 40 qhs colace 250 qAM [Doctor First Name 130] 30 qd prn robitussin syrup 5ml q6prn MOM 30ml qd prn MVI oxycodone hcl 5 q4 prn senna 2 tabs qHS trazodone 25 daily prn lasix 40 qod Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed pain. Disp:60 Tablet(s) Refills:0 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Use Percocet. Disp:30 Tablet(s) Refills:1 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY DAY (Every Day). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times day). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 6 hours) needed pain/fever. 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day: Use Percocet. Disp:60 Capsule(s) Refills:2 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) 8 days. Disp:32 Capsule(s) Refills:0 12. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times day): pin sites. Disp:1 500unit/g Refills:2 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] Aged - [Location (un) 550] Discharge Diagnosis: C2 type II dens fracture. Discharge Condition: neurologically stable. Discharge Instructions: Restart home medications usual. Please take newly prescribed medications instructed. Must wear collar times except bathing heavy lifting Diet low cholesterol high fiber. get steristrips wet tomorrow, may shower starting tomorrow. Watch incision redness, drainage, bleeding, swelling, develop fever greater 101.5 call Dr [Last Name (STitle) 17511] office may shower please keep incision covered tegaderms shower. Please keep incision clean, dry, intact till see Dr. [Last Name (STitle) ] clinic. * Increasing pain * Fever (>101.5 F) Vomiting * Inability eat drink * Reddness/swelling/discharge wounds * Anything concerns you. Followup Instructions: Please follow-up Dr. [Last Name (STitle) ] 8 weeks. Please call [Telephone/Fax (1) 1669] make appointment. Please keep following appointments: Provider: [Name10 (NameIs) 326] [Name11 (NameIs) ] DX RM2 RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2140-3-4] 1:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 98306], [Name12 (NameIs) 16569] RNC Date/Time:[2140-4-4] 1:20 Provider: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern1) 21], M.D. Date/Time:[2140-4-11] 3:30	[ "2724" ]
Admission Date: [2126-2-27] Discharge Date: [2126-3-5] Date Birth: [2050-6-17] Sex: F Service: CCU HISTORY PRESENT ILLNESS: 75 year-old woman past medical history hypertension, hypercholesterolemia transferred [Hospital6 33] emergent cardiac catheterization since presented hospital earlier evening admission complaints 6 10 abdominal indigestion. patient noted back pain, denies nausea vomiting. Electrocardiogram showed ST segment elevations 6 mm leads V2, V3 5 mm changes V5, 3 mm V6 3 mm changes leads 2 AVL. patient old right bundle branch block reciprocal changes inferior leads. patient given Lopressor, nitroglycerin Integrilin outside hospital chest pain decreased 1.5 10. note patient similar complaints Sunday. time complaints associated nausea vomiting well. catheterization laboratory patient underwent stenting mid left anterior descending coronary artery lesion due 50% proximal 50% first septal 100% mid occlusion. patient also underwent percutaneous transluminal coronary angioplasty left anterior descending coronary artery beyond flow stent. patient multiple infusions intracoronary nitroglycerin Diltiazem improve flow. Hemodynamically patient's right atrium pressure 10, PA 42/21, wedge pressure 26, cardiac output 3.24, cardiac index 1.95, FVR 2100. patient given 10 mg intravenous Lasix transferred Coronary Care Unit. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Status post appendectomy. ALLERGIES: Penicillin causes rash. MEDICATIONS: 1. Atenolol 50 day. 2. Lipitor 10 day. FAMILY HISTORY: Negative coronary artery disease. Father aortic aneurysm. Mother stroke. SOCIAL HISTORY: Former tobacco smoker half pack per day five yeas. Alcohol dinner occasionally. drugs. lives home older sister. PHYSICAL EXAMINATION ADMISSION: Blood pressure 150/80. Pulse 78. O2 sat 96% 2 liters. general, pleasant elderly woman acute distress. HEENT normocephalic, atraumatic. Pupils equal, round reactive light. Extraocular movements intact. Mucous membranes moist. Clear oropharynx. Cardiovascular regular rate rhythm. Normal S1 S2. 1 6 systolic ejection murmur. JVP 8 cm. Lungs clear auscultation anteriorly. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities clubbing, cyanosis edema. Good dorsalis pedis pulses posterior tibial pulses 2+ bilaterally. Right groin arterial sheath Swan place. Skin rashes lesions. LABORATORY DATA: White blood cell count 11.4, hematocrit 38.9, platelets 319, sodium 138, K 4.2, chloride 103, bicarb 26, BUN 23, creatinine 1.0, albumin 4.1, troponin 0.79. Electrocardiogram described previously. HOSPITAL COURSE: 75 year-old woman history hypertension, hypercholesterolemia status post large anterior myocardial infarction placement stent mid left anterior descending coronary artery. catheterization patient noted elevated wedge pressure residual lesion left circumflex, intervened on. 1. Coronary artery disease: patient large anterior myocardial infarction catheterization results noted above. patient continued aspirin, Plavix, Integrilin 18 hours discontinued. Also continued heparin beta-blocker continued tolerated. patient continued Lipitor 80 mg weaned nitro drip. Otherwise patient remained mostly chest pain free throughout course stay. started beta-blocker titrated tolerated patient evaluated EP team possible risk stratification future secondary anterior myocardial infarction decreased ejection fraction. continue episodes telemetry tachycardia exertion plans made outpatient Holter monitor outpatient stress six weeks time wave alternans time follow Dr. [Last Name (STitle) ] following studies reassess obtuse marginal right coronary artery lesions possible reintervention. patient also started low level Coumadin three four months anticoagulation anterior myocardial infarction hypokinesis anterior wall decreased ejection fraction. also started Lovenox bridge waiting Coumadin become therapeutic followed outpatient. Goal INR 1.5 time discontinued Lovenox. patient given teaching Lovenox stay understood injections. Otherwise patient also started ace inhibitor improve cardiac function decreased ejection fraction. 2. Congestive heart failure: patient ejection fraction 35% anterior myocardial infarction. akinesis mid distal anterior septum, distal anterior wall apical akinesis patient continued ace inhibitor load reduction started low dose Coumadin. patient's Os monitored receive Lasix prn basis. transfused one unit blood hematocrit less 30 followed dose Lasix bibasilar crackles following blood. 3. Hematuria: patient hematuria, likely secondary traumatic Foley placement admission, however, patient recommended outpatient cystoscopy urology follow get evaluated acute process resolved. 4. Nutrition: patient continued cardiac diet electrolytes followed closely. patient seen evaluated physical therapy acute needs rehab physical therapy. patient ambulating without difficulty without desaturation orthostasis. DISCHARGE CONDITION: Good. Discharged services Lovenox teaching. patient ambulating without difficulty requiring oxygen. DISCHARGE DIAGNOSES: 1. Anterior wall myocardial infarction. 2. Congestive heart failure. 3. Hypertension. 4. Hypercholesterolemia. 5. Hematuria. DISCHARGE MEDICATIONS: 1. Lovenox 100 mg subq q day INR greater 1.5. 2. Coumadin 5 mg po q day three four months goal INR 1.5. 3. Toprol XL 100 mg one po q day. 4. Lisinopril 10 mg one po q day. 5. Sublingual nitroglycerin prn. 6. Atorvastatin 80 mg po q day. 7. Plavix 75 mg one po q day. 8. Aspirin 325 mg one po q day. DISCHARGE FOLLOW UP: patient follow primary care physician [Name9 (PRE) 2974]. patient INR checked time adjusted accordingly. patient follow outpatient neurologist establish local cardiologist sees local primary care physician. [Name10 (NameIs) ] follow Dr. [Last Name (STitle) ] [2126-4-17]. patient Holter monitor placed [4-8] return stress test wave alternans [4-9]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2126-3-5] 04:24 T: [2126-3-6] 08:50 JOB#: [Job Number 54527]	[ "4280", "2720", "4019" ]
Admission Date: [2126-8-30] Discharge Date: [2126-9-8] Date Birth: [2054-2-16] Sex: F Service: CARDIOTHORACIC Allergies: Relafen Attending:[First Name3 (LF) 4679] Chief Complaint: Recurrence lung cancer Major Surgical Invasive Procedure: [2126-8-30]: Redo right thoracotomy, Lysis adhesions decortication lung, Wedge resection right lower lobe lung cancer. History Present Illness: Ms. [Known lastname 6610] 72 year-old woman performed right thoracotomy, right lower lobe superior segmentectomy [2125-7-27]. pathology revealed 2.5cm, moderately differentiated, adenocarcinoma negative margins. lymph nodes negative. pT1bN0Mx, stage IA. seen clinic [2126-7-16] local recurrence noted CT. [2126-7-19] PET showed FDG-avid subpleural nodule right lower lobe, compatible recurrence well chest wall region right 5th 6th ribs new [2125-7-3] also concerning recurrence. underwent core biopsy [2126-8-2] path revealed recurrent adenocarcinoma. denies symptoms time. Past Medical History: Hypertension Hyperlipidemia breast CA s/p lumpectomy [2118] nodal negative adjuvant chemorads Renal angiomyolipoma Emphysema PSH: RLL superior segmentectomy [2125-7-27], Recurrent PTX requiring partial resection via thoracotomy Social History: quit smoking [2109] smoked 40 years 2 packs day. Denies alcohol use. Unfortunately, husband terminal gastric cancer, hospitalized VA greatly upsets patient. Family History: two daughters healthy. history allergies emphysema family. Physical Exam: Gen: NAD, anxious Neck: [Doctor First Name ] Chest: clear ausc, incisions c,d,i Cor: RRR murmur Ext: CCE Pertinent Results: ADMISSION LABS [2126-8-30] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333 [2126-8-30] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-106 HCO3-22 AnGap-16 [2126-8-30] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5* DISCHARGE LABS [2126-9-7] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2* MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455* [2126-9-7] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136 K-3.9 Cl-96 HCO3-30 AnGap-14 [2126-9-7] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8 [8-30] CXR post op Right pneumothorax post surgery three chest tubes place [9-7] CXR Interval removal right basilar chest tube. continues subcutaneous emphysema within right lateral chest wall soft tissues. Post-surgical changes right hemithorax lung stable. Stable right lateral pleural thickening right basilar pleural thickening could post-operative represent pleural fluid. However, appearance stable. pneumothorax seen. left lung remains well inflated clear. Cardiac mediastinal contours stable. Clips right upper quadrant consistent cholecystectomy. pulmonary edema. Brief Hospital Course: Patient admitted [2126-8-30] thoracic surgery service planned right thoracotomy, right lower lobe wedge resection decortication. tolerated procedure well, extubated recovered PACU prior transferred ICU stable condition. full details please see operative report. Three chest tubes placed procedure postoperative chest x-ray showed expected right pneumothorax post surgery three chest tubes place. Pathology revealed 1.8 cm poorly differentiated adenocarcinoma negative margins positive nodes. started clear liquid diet, pain controlled epidural started home medications. POD 1 diet advanced regular transferred surgical floor ICU. POD 2 noted increased somnolence thought related pain medications epidural turned narcotics breakthrough pain discontinued. given unit PRBC Hct 20.3 appropriate increase 24.4 improved somnolence. POD 3 metoprolol started elevated systolic blood pressures. continued air leak three chest tubes. epidural discontinued foley catheter removed. started oxycodone tramadol pain. POD 4 air leak stopped anterior chest tube removed. posterior chest tube removed POD 6. POD 7 noted felt dizzy getting bed found atrial fibrillation RVR. given metoprolol without effect given IV diltiazem return sinus rhythm. Cardiac enzymes negative monitored telemetry without recurrence. POD 8 air leak resolved basilar chest tube removed. post pull chest xray showed PTX. pain well controlled, tolerating diet ambulating without assistance, discharged home POD 9 instructions follow Dr.[Name (NI) 5067] clinic chest x-ray. Medications Admission: 1. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] twice day Rinse mouth use 2. Nortriptyline 30 mg PO HS 3. Pravastatin 40 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen 650 mg 1 tablet(s) mouth every 6 hours Disp #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) mouth twice day Disp #30 Capsule Refills:0 3. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] twice day Rinse mouth use 4. Nortriptyline 30 mg PO HS 5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX oxycodone 5 mg [12-10] tablet(s) mouth every 4 hours Disp #50 Tablet Refills:0 6. Pravastatin 40 mg PO DAILY 7. Senna 1 TAB PO BID RX sennosides [senna] 8.6 mg 1 tablet mouth twice day Disp #30 Tablet Refills:0 8. Tiotropium Bromide 1 CAP IH DAILY 9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 10. Metoprolol Tartrate 12.5 mg PO BID HTN Hold SBP < 100 HR < 60 RX metoprolol tartrate 25 mg Half tablet(s) mouth twice day Disp #15 Tablet Refills:0 Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Recurrent lung cancer Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted hospital surgery lung. done well procedure may return home continue recovery. dressing site chest tube- may removed 24 hours. leave incision open air that. may shower dressing place. Please take prescribed pain medication needed. Constipation problem narcotic use, therefore drink plenty fluid stay well hydrated use stool softener taking narcotics. drive taking narcotic pain medications. hospital, noticed heart rhythm called atrial fibrillation. able convert rhythm back normal using medication; please ask primary care doctor need tests treatment. also started new medication called Metoprolol high blood pressure new dysrhythmia, please ask primary care doctor need continue it. develop chest pain, shortness breath symptoms concern you, please call surgeon go nearest Emergency Room. Thank allowing us participate care. Followup Instructions: Please follow Dr. [First Name (STitle) ] 2 weeks. Please call [Telephone/Fax (1) 2348] schedule follow appointment 2 weeks chest x ray. Please report [Location (un) ] [Hospital Ward Name 23*] center 30 min prior appointment chest x-ray. Please follow primary care doctor within week discharge.	[ "4019", "2724" ]
Admission Date: [2126-11-1] Discharge Date: [2126-11-6] Date Birth: [2069-11-6] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 7333] Chief Complaint: s/p PEA arrest Major Surgical Invasive Procedure: None History Present Illness: 58 year old male history atrial fibrillation, DM2, prior MI presents s/p PEA arrest OSH VATS. . Patient intubated unresponsive arrival, history obtained outside records. . early [Month (only) 359], sore throat felt poorly. went PCP treated 10 days ammoxicillin. treated penicillin dental extraction. Shortly this, became progressively short breath. saw PCP referred Cardiology (Dr. [Last Name (STitle) 77919]. time CXR performed showed opacification right lower [12-9] [12-8] hemithorax, interpreted infiltrate + pleural effusion. also stress echocardiogram cardiac catheterization planned. chest X-ray repeated [2126-10-28], unchanged. cath deferred scheduled undergo VATS possible pleural decortication. . admitted [Hospital3 26615] [2126-10-30] VATS bronchoscopy. 2600 cc straw colored pleural fluid removed, pleural biopsy taken. end procedure, prior extubation, patient drop blood pressure suffered PEA arrest. Patient received defibrillation, epinephrine, chest compresions 17 minutes. returned [Location 213] sinus rhythm, transferred ICU. put lasix drip. echo demonstrated pericardial effusion, CT PA demonstrated PE. labs significant WBC 12. Cardiac enzymes flat. treated levaquin unasyn presumed PNA. weaned sedation responded noxious stimuli. evaluated neurology recommended MRI EEG. transferred [Hospital1 18] cardiology neurology evaluation. transfer, heparin drip, midazolam/fentanyl sedation mechanical ventilation (AC). Past Medical History: - Atrial Fibrillation - Diabetes Type II - H/O MI Social History: -Tobacco history: Quit smoking three years ago, 1 ppd x 20 years previously -ETOH: 12 pack weekends -Illicit drugs: Family History: NC Physical Exam: VS: T= 99.7 BP= 126/81 HR= 78 RR= 16 O2 sat= 100/ AC FiO2 100, Tv 550, RR 16, PEEP 5 GENERAL: Intubated, sedated, responsive commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP 10 cm. CARDIAC: PMI located 5th intercostal space, midclavicular line. RR, normal S1, S2. m/r/g. thrills, lifts. S3 S4. LUNGS: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: c/c/e. femoral bruits. SKIN: stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ NEURO: Unresponsive commands. Pupils reactive light, corneal relfex intact. Babinski going. spontaneous movement observed. . time death: extubated Pertinent Results: [2126-11-1] 06:22PM BLOOD WBC-9.1 RBC-4.64 Hgb-14.7 Hct-41.6 MCV-90 MCH-31.8 MCHC-35.4* RDW-13.5 Plt Ct-222 [2126-11-1] 06:22PM BLOOD Neuts-74.9* Lymphs-17.0* Monos-5.7 Eos-0.7 Baso-1.8 [2126-11-1] 06:22PM BLOOD PT-15.6* PTT-32.2 INR(PT)-1.4* [2126-11-2] 04:11AM BLOOD ESR-30* [2126-11-1] 06:22PM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-136 K-3.7 Cl-98 HCO3-29 AnGap-13 [2126-11-1] 06:22PM BLOOD ALT-24 AST-51* CK(CPK)-100 AlkPhos-75 TotBili-2.1* [2126-11-2] 04:11AM BLOOD ALT-22 AST-50* AlkPhos-69 TotBili-2.0* [2126-11-3] 04:26AM BLOOD ALT-22 AST-54* AlkPhos-69 TotBili-2.4* [2126-11-1] 06:22PM BLOOD CK-MB-1 cTropnT-<0.01 [2126-11-1] 06:22PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1 [2126-11-2] 04:11AM BLOOD CRP-41.7* [2126-11-2] 04:11AM BLOOD [Doctor First Name ]-NEGATIVE dsDNA-NEGATIVE [2126-11-1] 06:27PM BLOOD Type-ART pO2-386* pCO2-39 pH-7.48* calTCO2-30 Base XS-6 [2126-11-3] 05:12AM BLOOD Type-ART pO2-143* pCO2-39 pH-7.47* calTCO2-29 Base XS-5 [2126-11-1] 06:27PM BLOOD Lactate-1.6 . EEG: abnormal routine EEG due presence low-voltage background invariant nonreactive external stimulation. finding suggests diffuse severe encephalopathy, caused hypoxic-ischemic injury, toxic-metabolic changes, medication effect, among things. focal abnormalities epileptiform features noted. . PCXR: ET tube tip 5.2 cm carina. NG tube tip passes diaphragm tip stomach. Diffuse pericardial calcification noted, circumferential. Mediastinum minimally widened might related portable technique study. minimal vascular congestion overt edema. Left retrocardiac opacity might represent area atelectasis, aspiration infectious process closely monitored. . TTE: left atrium elongated. right atrium moderately dilated. estimated right atrial pressure 10-20mmHg. mild moderate regional left ventricular systolic dysfunction basal mid inferior, inferolateral, anterolateral hypokinesis. Due suboptimal technical quality, additional focal wall motion abnormality cannot fully excluded. Overall left ventricular systolic function mildly depressed (LVEF= 40%). Unable assess left ventricular diastolic function. Right ventricular chamber size free wall motion normal. abnormal septal motion/position. ascending aorta mildly dilated. aortic valve leaflets mildly thickened (?#). aortic valve stenosis. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral regurgitation seen. pericardial effusion. anterior space likely represents prominent fat pad. . MR HEAD W/ W/O CON: 1. Extensive confluent areas decreased diffusion bilateral parietal occipital [Month/Day/Year 3630] parts frontal lobes likely related cortical infarction degree cortical swelling. Spreading temporal lobes, basal ganglia right cerebellar hemisphere probably left cerebellar hemisphere. Correlate clinically consider followup/correlation brain scan. 2. Area increased signal intensity T2 FLAIR sequences right frontal [Last Name (LF) 3630], [First Name3 (LF) ] relate changes parenchyma surrounding small developmental venous anomaly. However, given lack prior studies extent FLAIR hyperintense area, measures 2.1 x 2.6 cm, consider followup assess stability/progression exclude associated low-grade neoplasm. 3. Mucosal thickening mastoid air cells sides, right left. . Brief Hospital Course: #. s/p PEA arrest. Post-op/peri anesthesia hypotension likely precipitant PEA. Possible contribution hypoxia given lung collapse seen CT. CT PA negative PE, echo negative tamponade. Labs essentially normal, cardiac enzymes negative. Neurology consulted EEG MRI head done, consistent poor neurologic prognosis. Neurology team explained prognosis patient's family agreed would within wishes exist without meaningful interaction. NEOB initially contact[Name (NI) ] pt. longer possible donor extubated. . # Respiratory Failure/Pleural Effusion: Patient never extubated post-thoracentesis. Continued levaquin unasyn given concern aspiration/oral flora given unilateral PNA, recent tooth extraction alcohol history. Pleural fluid analysis empyema, suggestive exudate. Fluid cytology negative. Patient overbreathing vent excellent RSBI prior extubation. made DNR/DNI prior extubation. successfully extubated [11-4] morphine drip given scopolamine patch comfort measures. expired morning [11-6]. Autopsy requested family. Medications Admission: HOME MEDICATIONS: Metformin 1000mg PO bid ASA 325mg PO daily Glyburide 5mg PO bid Imdur 30mg PO daily . MEDICATIONS TRANSFER: Combivent Heparin gtt 900 U/hr Unasyn 3gm IV q6 Levaquin 750 mg q24 Lasix 40mg IV q daily Discharge Disposition: Expired Discharge Diagnosis: s/p PEA arrest Death Discharge Condition: Expired	[ "486", "4019", "4280" ]
Admission Date: [2176-5-31] Discharge Date: [2176-6-14] Date Birth: [2101-7-5] Sex: F Service: SURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: Constipation, fatigue, weight loss Major Surgical Invasive Procedure: Resection transverse colon splenic flexure, colocolostomy, resection small bowel (en bloc) enteroenterostomy feeding jejunostomy. History Present Illness: Mrs [Known lastname 1391] 74F presents several month history constipation, diarrhea, occasional nausea/vomiting, weight loss approx 25lbs past 6 months. first sought medical attention 3 weeks admission, workup, including colonoscopy CT scan, showed mass transverse colon. Biopsy showed moderately differentiated adenocarcinoma. denies black bloody stools, dysuria. Past Medical History: CAD CABG [9-/2172] Hypothyroidism Recent onset heartburn symptoms, formal dx GERD Social History: 30-40py smoking history Widowed 6 years 3 Children Family History: Mother died pancreatic cancer, father prostate cancer Physical Exam: Physical exam discharge: VS: RRR CTAB Abd soft, non-tender jejunostomy tube place. J-tube site free erythema induration. Brief Hospital Course: Ms [Known lastname 1391] admitted [2176-5-31] begin nutritional optimization preparation surgery. pre-operative cardiology clearance obtained cardiac intervention required. central line placed [6-1] total parenteral nutrition initiated, although pt continued attempt self-support oral intake. CT scan [6-5] pre-operative planning encouraging, showed metastatic lesion invading mesentery likely involvement celiac mesenteric vessels. underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) ] prep Fleets #1 prep [6-5], taken operating room [6-6]. Please refer operative report Dr [Last Name (STitle) 957] details procedure. Post-operatively noted markedly bradycardic, heart rates low 29 blood pressures proved difficult measure either machine direct auscultation. thus placed MICU overnight advice cardiology service, felt unlikely event HR dropped low unable support blood pressure, would essential close monitoring. Fluid resuscitation continued, patient's HR gradually normalized. Electrophysiology consulted, recommended pacemaker time, rhythm Wenckebach constitute indication pacemaker. Although continued TPN post-operatively, functional level improved returned oral intake, tubefeeds supplement. [6-11] began complain suprapubic burning pain, urinalysis negative UTI, pain deemed post-surgical. improved, TPN stopped, tubefeeds oral intake increased, central line removed. discharged home services [6-14]. Follow Heme/Onc arranged, pt expressed wish follow Dr [Last Name (STitle) ] [Hospital3 ]. also recommended seek care [Hospital3 35292] service [Hospital1 18], modality may well suited tumor. Medications Admission: Atenolol 25 Fosamax 35 q week Levoxyl 88mcg 81mg ASA Ambien prn Vicodin prn, MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). Disp:30 Tablet(s) Refills:2 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. Disp:40 Tablet(s) Refills:0 3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times day) 2 weeks. Disp:42 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Hospital3 7571]Nursing Assc. Discharge Diagnosis: Colon cancer Discharge Condition: Good Discharge Instructions: Take medications prescribed. drive taking narcotic pain medication percocet vicodin. Please follow VNA's instructions tubefeeds. develop fevers, chills, nausea/vomiting, cessation bowel movements flatus, difficulty flushing J-tube, severe abdominal pain, concerning symptoms, please contact office local emergency room. Please call Dr[Name (NI) 6275] office schedule follow appoitnment. also able put contact [Name (NI) 35292] office, help arrange chemotherapy treatments. Dr[Name (NI) 35293] office contacting Dr [Last Name (STitle) ] followup well, hear within one week please call office. Followup Instructions: Please call Dr[Name (NI) 6275] office schedule follow appoitnment. also able put contact [Name (NI) 35292] office, help arrange chemotherapy treatments. Dr[Name (NI) 35293] office contacting Dr [Last Name (STitle) ] followup well, hear within one week please call office.	[ "2449" ]
Admission Date: [2162-6-3] Discharge Date: [2162-6-9] Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 1402] Chief Complaint: lethargy, bradycardia, fever Major Surgical Invasive Procedure: None History Present Illness: 89M w/ COPD, Afib coumadin, moderate dementia urinary retention indwelling foley, admitted altered mental status, admitted MICU fever, new complete heart block question sepsis. morning admission, patient noted fatigued unable walk. baseline, lives [Hospital1 100] generally oriented self answer basic questions, walk walker. exam rehab, bradycardia 40s, BP 154/64, O2 sat 94% RA, temp 99.3. EKG showed complete heart block. transferred ED evaluation. ED, initial VS were: 101.3 44 155/37 32 87% RA. Hypoxia improved 2L nasal cannula. UA sig UTI (>182 WBC, lrg leuks, pos nitrates, many bacteria). CXR concerning ? infiltrate. Pressures stable SBPs 120s-130s. Got 2L IVF, ceftriaxone azithro. Confirmed 3rd degree heartblock EKG. Labs showed acute renal failure (Cr 1.6, baseline 1.0), lactate 2.7, concern mild sepsis. 18G 20G placed. A&O&1. Patient confirmed DNR, would consider PPM. foley catheter replaced. arrival MICU, patient resting comfortably. questioning daughter denies pain. felt appeared better morning. discussion, would like temporary pacing necessary. would like father DNR/DNI, would okay reversing status pacemaker placement. Past Medical History: - Bacteremia [11/2161] VRE [Female First Name (un) ] - COPD (unclear history, always nonsmoker) - HTN meds - AF coumadin - colon cancer [2152] - dementia (recognizes children oriented place able converse normally oriented place time), significant behavioral component - History TB, found 10mm PPD [2153], negative CXR treated [2153] 9 months latent TB. CXR repeat [2156] looked increased density bases - BPH chronic indwelling foley, h/o [Year (4 digits) 40097] E.Coli urine infection - GERD - anemia - intermittent complete heart block. Asymptomatic, discussion family, PPM clear benefit. Social History: Lives [Hospital 100] Rehab. Never smoker. Able walk walker assist. Diet pureed/nectar thickened several months, recently switched back thin liquids. Family History: Daughter know significant family history. Physical Exam: Admission Exam: VS: 101.3 44 155/37 32 87% RA General: Alert, oriented self, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP mildly elevated 8-10cm, LAD CV: Distant heart sounds, marked bradycardia, normal S1 + S2, audible murmurs, rubs, gallops Lungs: Clear auscultation anteriorly, wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley place Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: CNII-XII intact, moving four extremities, unable cooperate. Discharge Exam: Vitals: afebrile x2.5days, Tc 98.5, 150/85, 51, 18, 99%RA General: resting comfortably bed, acute distress, interactive, smiling HEENT: Sclera anicteric, dryMM Neck: supple, JVP elevated, LAD CV: bradycardiain 50s, normal S1 + S2, audible murmurs, rubs, gallops Lungs: + mild rales bilaterally bases, rhonchi/wheezes. Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: indwelling foley place Ext: room temperature, improved cap refill, 2+ pulses, clubbing, cyanosis edema Dementia: speaking sensical Russian currently, oriented self. baseline. Pertinent Results: Admission Labs: [2162-6-3] 02:20PM BLOOD WBC-14.0# RBC-5.66# Hgb-13.2# Hct-44.6# MCV-79* MCH-23.3* MCHC-29.6* RDW-15.8* Plt Ct-221 [2162-6-3] 02:20PM BLOOD Neuts-89.0* Lymphs-6.7* Monos-3.7 Eos-0.6 Baso-0.2 [2162-6-3] 02:20PM BLOOD PT-32.5* PTT-39.6* INR(PT)-3.2* [2162-6-3] 02:20PM BLOOD Glucose-145* UreaN-27* Creat-1.6* Na-138 K-7.4* Cl-106 HCO3-21* AnGap-18 [2162-6-3] 02:20PM BLOOD ALT-49* AST-76* AlkPhos-81 TotBili-0.5 [2162-6-3] 02:20PM BLOOD Lipase-40 [2162-6-3] 02:20PM BLOOD cTropnT-0.06* [2162-6-3] 02:20PM BLOOD Albumin-3.8 Calcium-8.8 Phos-2.6* Mg-2.4 [2162-6-3] 02:28PM BLOOD Lactate-2.7* K-5.7* Admission UA: [2162-6-3] 02:30PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.020 [2162-6-3] 02:30PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2162-6-3] 02:30PM URINE RBC-9* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 Repeat UA: [2162-6-5] 09:00PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.019 [2162-6-5] 09:00PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2162-6-5] 09:00PM URINE RBC-7* WBC-5 Bacteri-NONE Yeast-NONE Epi-0 Lactate trend: [2162-6-3] 02:28PM BLOOD Lactate-2.7* K-5.7* [2162-6-4] 12:33AM BLOOD Lactate-1.4 [2162-6-5] 07:51PM BLOOD Lactate-3.4* [2162-6-5] 08:14PM BLOOD Lactate-1.4 Troponin Trend: [2162-6-3] 02:20PM BLOOD cTropnT-0.06* [2162-6-3] 10:10PM BLOOD CK-MB-3 cTropnT-0.06* [2162-6-5] 04:06AM BLOOD CK-MB-3 cTropnT-0.05* WBC trend: 14.0->11.7->10.1->9.2->7.9->8.2->7.8->6.9 Discharge Labs: [2162-6-9] 06:49AM BLOOD WBC-6.9 RBC-5.05 Hgb-11.9* Hct-39.7* MCV-79* MCH-23.6* MCHC-30.0* RDW-16.1* Plt Ct-257 [2162-6-9] 06:49AM BLOOD PT-22.8* PTT-32.0 INR(PT)-2.2* [2162-6-9] 06:49AM BLOOD Glucose-77 UreaN-22* Creat-0.9 Na-146* K-4.4 Cl-114* HCO3-24 AnGap-12 [2162-6-9] 06:49AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2 MICRO: [2162-6-3] MRSA SCREEN MRSA SCREEN-negative [2162-6-3] URINE URINE CULTURE- Mixed Flora [2162-6-3] BLOOD CULTURE Blood Culture, Routine-PENDING [2162-6-3] BLOOD CULTURE Blood Culture, Routine-PENDING [2162-6-8] STOOL C. difficile DNA amplification assay-negative [2162-6-5] BLOOD CULTURE Blood Culture, Routine-PENDING [2162-6-5] BLOOD CULTURE Blood Culture, Routine-PENDING [2162-6-5] URINE URINE CULTURE-mixed flora IMAGING: [2162-6-3] EKG: Sinus rhythm high grade A-V block. Baseline artifact obscures interpretation appears complete heart block present junctional escape approximately 40 beats per minute. Compared previous tracing [2161-5-29] heart block new. High grade A-V block new. TRACING #1 [2162-6-4] EKG: High grade A-V dissociation junctional escape approximately 34 beats per minute. appear conducted P waves likely isorhythmic dissociation. variation P-P interval may due ventriculophasic affect. Compared previous tracing [2161-5-29] heart block persists. TRACING #2 [2162-6-3] CXR: Low lung volumes. Probable bibasilar atelectasis aspiration difficult exclude. Possible trace bilateral pleural effusions. [2162-6-4] Echo: left atrium mildly dilated. atrial septal defect seen 2D color Doppler. mild symmetric left ventricular hypertrophy normal cavity size regional/global systolic function (LVEF>55%). ventricular septal defect. Right ventricular chamber size free wall motion normal. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. Mild (1+) aortic regurgitation seen. aortic regurgitation jet eccentric, directed toward anterior mitral leaflet. mitral valve leaflets mildly thickened. mitral valve prolapse. Mild (1+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. mild pulmonary artery systolic hypertension. pericardial effusion. Compared prior study (images reviewed) [2161-11-18], clear change. [2162-6-5] CXR: heart moderately enlarged. moderate-sized left effusion increased compared prior. pulmonary vascular redistribution alveolar infiltrate suggesting element fluid overload; however, addition, dense alveolar infiltrate involving left lower lobe. unclear due infectious process. Chronic right upper lobe lower lobe lung changes visualized. IMPRESSION: 1. New infiltrate left lower lobe. 2. Increased fluid overload. Brief Hospital Course: 89M w/ COPD, Afib coumadin, moderate dementia urinary retention indwelling foley, admitted altered mental status, new complete heart block infection unclear source. Acute Issues: # Complete heart block: Patient previously PR interval 218, suggesting progressive nodal disease. narrow QRS, slow escape rhythm. Trial atropine suggestive infranodal disease, telemetry also shows multiple foci disease. course hospital stay, heart block resolved intermittently heart rate time discharge persistently 50-60s. result family discussion risks benefits PPM elderly patient end stage dementia intermittent asymptomatic complete heart block coumadin afib, potential (not guaranteed) benefits PPM placement would outweight potential risks. # Fever/UTI/Infection unclear source: Patient presented fever 101.3F grossly positive UA. likely source urinary, given positive UA. Indwelling foley replaced ED. CXR similar prior. history resistant bacteria (VRE [Month/Day/Year 40097] e.coli), iniatially covered broadly Meropenem Linezolid [Last Name (un) ] Daptomycin. Urine culture finalized mixed flora evidence VRE [Last Name (LF) 40097], [First Name3 (LF) ] pt narrowed ceftriaxone. 10 hours last dose meropenem, became febrile 102.9F, venous lactate 2.4. UTI cause high fevers, ddx included prostatitis, pyelonephritis, PNA. Repeat UA without bacteria repeat urine culture mixed flora. CXR showed fluid overload possible infiltrate/PNA, sypmtoms. C. diff PCR negative. Blood cultures NGTD. rebroadened Meropenem (Daptomycin restarted, suspicion gram positive infection) WBC continued trend without subsequent fevers. Patient lost IV access (pulling IVs EKG leads) replacement IVs successfully placed. Given source infection unknown, failed trial narrowing antibiotics, continued [First Name3 (LF) ] 1gm IM daily remainder antibiotic course. continued [First Name3 (LF) 49799] 2 days inhouse afebrile normal WBC, continue course [2162-6-12]. # Respiratory Alkalosis/Hypoxia/dCHF: transfer MICU, noted tachypneic decreased O2 saturation. ABG showed respiratory alkalosis, likely due hyperventilation 2/2 hypoxia: pH 7.53, pCO2 23, pO2 62. Placed O2 repeat ABG showed pH 7.40, pCO2 40, pO2 68. CXR showed acute congestive heart failure posible infiltrate LLL. Echo showed mild pulmonary hypertension (increased TR gradient) nml EF. CHB likely decreased CO caused mild CHF. Given 10mg IV lasix gentle diuresis good urine output improvement O2 sats. Patient without symptoms cough. WBC continued trend current meropenem/[Last Name (LF) 49799], [First Name3 (LF) ] pneumonia treatment initiated. # Hypertension (Occult Hypoperfusion): Patient carries diagnosis HTN, though noted antihypertensives outpatient. Since CHB, patient noted higher BPs (SBPs 150s-180s). low HRs (30-40s), patient dry cool, suggesting vascularly constricted, likely effort maintain perfusion tissues CHB. Venous lactate 3.4, arterial lactate 1.4, supporting likely occult hypoperfusion [2-4] CHB. Several days admission, heart rates improved 50-60s, rarely complete heart block. elevated blood pressure never rose SBP 200, tolerated effort maintain perfusion tissues. Chronic Issues: # Dementia: Patient end stage dementia, oriented self able communicate sensically. Initially found fatigued able walk around. Family concerned baseline terms mental status time, however treatment infection returned baseline MS. may element decreased MS heart rates 30s, however infection improved, heart rate improved, difficult assess. Patient continued home mirtazipine zyprexa rare doses zydis agitation (which family reports baseline). # [Last Name (un) ]: Patient presented [Last Name (un) ] (Cr 1.6, baseline noted 1.0). Likely due hypoperfusion infection compounded complete heart block. Cr trended since admission, discharge 0.9. # Afib: CHADS score 2, coumadin goal [2-5]. Presented INR 3.2. Coumadin initially held, restarted remained therapeutic home dose 3mg daily except Mondays takes 3.5mg daily. # COPD: Written albuterol ipratropium nebs needed wheezing. # BPH: Continued finasteride chronic foley, exchanged ED [2162-6-3]. Transitional Issues: DNR/DNI Given patient intermittently complete heart block, anticoagulated end stage dementia, given appears baseline mental status currently, decided risks outweight benefits pacemaker placement. long blood pressure <200, elevated blood pressures tolerated patient bradycardic. higher blood pressures natural compensation maintain blood perfusion body cardiac output decreased slower heart rate. Medications Admission: - mirtazapine 30mg QHS - trazodone 50mg QHS PRN insomnia - Senna 17.2mg QHS - Miralax 17gm daily - Bacitracin 1 application [Hospital1 ] - finasteride 5mg daily - tylenol 650mg Q6hrs PRN - olanzapine 2.5mg daily - warfarin 3mg daily TuWeThFrSaSu - warfarin 3.5mg daily Mo Discharge Medications: 1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO bedtime. 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO bedtime needed insomnia. 3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. polyethylene glycol 3350 17 gram Powder Packet Sig: One (1) Powder Packet PO DAILY (Daily). 5. bacitracin Topical 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed pain. 8. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 3 mg Tablet Sig: One (1) Tablet PO daily except 3.5mg Mondays. 10. warfarin 1 mg Tablet Sig: 3.5 Tablets PO 1X/WEEK (MO): 3mg daily, except 3.5mg Mondays. 11. [Hospital1 49799] 1 gram Recon Soln Sig: One (1) gram Injection day 4 days: Give 2pm daily 4 doses, last dose [2162-6-12] 2pm. Mix injection lidocaine lessen pain injection. Disp:4 gram Refills:0 12. miconazole nitrate 2 % Aerosol Powder Sig: One (1) application Topical four times day: fungal rash buttocks. Discharge Disposition: Extended Care Facility: [Hospital6 459] Aged - MACU Discharge Diagnosis: Primary Diagnosis: Complete Heart Block, Urinary Tract Infection Secondary Diagnosis: Hypertension Dementia Acute Kidney Injury Atrial Fibrillation COPD BPH Discharge Condition: Mental Status: Confused - always. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). Discharge Instructions: Dear Mr. [Known lastname 55195], pleasure taking care fo [Hospital1 827]. admitted extreme fatigue irregular heart beat. admission found urinary tract infection, treated for. Additionally, noted irregularly slow heart rhythm called Complete Heart Block, however improved admission. decided risks outweight possible benefit placing pacemaker problem. [Name (NI) ] improved treatment infection safe discharge. Please make following changes outpatient medication regimen: START [Name (NI) ] 1mg intramuscular injection daily 4 days. START miconazole powder applied 4 times daily fungal rash buttocks. Keep area dry clean. changes made outpatient medications. Continue medications previously prescribed. Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs. Followup Instructions: followed doctors [First Name (Titles) ] [Last Name (Titles) 100] Rehab.	[ "5990", "5849", "4280" ]
Admission Date: [2109-6-6] Discharge Date: [2109-6-7] Date Birth: [2051-9-7] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 443] Chief Complaint: afib w/ RVR Major Surgical Invasive Procedure: None History Present Illness: Ms. [Known lastname 85533] 57 year old woman hard control HTN hypothyroidism, transferred OSH [Hospital1 18] found atrial fibrillation TEE/DCCV. . Ms. [Known lastname 85533] states past week mild chest pain, last several minutes. also shortness breath evenings kept sleeping. questioning states chest pain addition palpitations feeling skipped beats going two years. Throughout time thought "nerves." went PCP, [Name10 (NameIs) ] seen physician [Last Name (NamePattern4) ] 2 years, ECG done office. found atrial fibrillation sent ED. . OSH, given metoprolol po iv without improvement heart rate. Initially labetalol increased stopped switched toprol XL. heart rates ranged 120s-130s. started coumadin lovenox. echo showed mildly decrease EF. labs: d-dimer negative, hct 41.9, cr 0.8, trop <0.01. . note, poorly controlled hypertension sbp<200s dbp>100s. reports compliant medications states infrequently goes PCP. [Name10 (NameIs) ] last time seen prior visit two years ago. . Currently, denies shortness breath chest pain. review systems, denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. denies recent fevers, chills rigors. S/he denies exertional buttock calf pain. review systems negative. . Cardiac review systems notable absence dyspnea exertion, paroxysmal nocturnal dyspnea, orthopnea, syncope presyncope. . ROS positive back/neck pain, chronic headaches, weight gain three weeks, chronic stable LE edema past 10 years. . Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. PAST MEDICAL HISTORY: - HTN poorly controlled - Afib new, ? going 2 years given funny feeling chest - Hypothyroidism - S/p ?thyroid parathyroid surgery Social History: - Cigs: 3 PYs 50s - etOH: denies - Illicits: denies - Works CNA - Kids [Country 19639] Family History: - Father: MI age 63 - Mother: CVA age 64 Physical Exam: Vital Signs: BP 150/90 HR 90 RR 16 98%RA GEN: Sitting bed NAD Cardiac: nl JVP, irregular rhythm, murmurs Resp: Clear lungs Abd: soft, NT ND Ext: edema noted Pertinent Results: [2109-6-6] 01:42PM %HbA1c-5.5 eAG-111 [2109-6-6] 12:20PM GLUCOSE-88 UREA N-16 CREAT-0.9 SODIUM-142 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-29 ANION GAP-13 [2109-6-6] 12:20PM estGFR-Using [2109-6-6] 12:20PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.3 [2109-6-6] 12:20PM TSH-2.5 [2109-6-6] 12:20PM TSH-2.5 [2109-6-6] 12:20PM NEUTS-78.2* LYMPHS-15.2* MONOS-3.6 EOS-2.4 BASOS-0.6 [2109-6-6] 12:20PM PLT COUNT-259 [2109-6-6] 12:20PM PT-16.9* PTT-27.5 INR(PT)-1.5* Brief Hospital Course: 57 yo female atrial fibrillation, severe hypertension diastolic heart failure. Initial plan TEE/cardioversion. TEE performed show clot. initially attempted DC cardioversion X 3 however attempts bring sinus. initiated sotalol good rate control established HRs < 100 however remained sinus rhythm. continued coumadin anticoagulation. hypertensive hypokalemic work-up hypertension initiated; renal artery ultrasound pending. Valsartan increased 80 160 daily improved BP control; spirinolactone discontinued. Labetalol discontinued given initiation sotalol. Plasma renin/angiotensin ordered pending. Given symptomatic improvement rate control, transferred floor management. evaluated [Doctor Last Name ] hearts monitor discharge; follow Dr [Last Name (STitle) 171] scheduled. also appointment PCP scheduled Wednesday [6-12] follow-up along lab check [Month (only) 766] [6-10] [Hospital3 ] INR potassium. Medications Admission: Benecar 40 + HCTZ 12.5 QD Labetolol 100mg PO BID Levothyroxine 100mcg PO daily Tylenol PRN Hx "water pills" Discharge Medications: 1. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Daily 4 PM. Disp:45 Tablet(s) Refills:2 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diovan HCT 160-12.5 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:0 5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times day). Disp:90 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed pain. 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Outpatient Lab Work Please get INR, Potassium, Magnesium, calcium, phosphate checked [Last Name (LF) 766], [6-10]. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: (1) Atrial fibrillation (2) Hypertension (3) Hypothyroidism Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [Known lastname 85533], admitted heart rate fast rhythm "atrial fibrillation" also high blood pressure. tried convert rhythm using electrical shock, however keep normal rhythm long. reason, started new medication hospital help control heart rates. also made medication changes help control blood pressure. changes medication scheduled below. need follow cardiologist Dr [Last Name (STitle) 171] outpatient, may try additional therapies try convert atrial fibrillation. . medication changes made hospitalization are: (1) Started warfarin, blood thinning medication, take every day. need take 3 mg daily. important medicine prevents heart forming blood clots atrial fibrillation. need see [Hospital3 ] [Hospital3 766] morning get labs checked medicine. Instructions attending clinic listed below. (2) Started Diovan HCT 160 - 12.5 mg medicine help lower blood pressure. (3) Started sotalol 120 mg twice day. medicine helps prevent heart rate going fast. (4) Started amlodipine 10 mg daily - another medicine help control blood pressure. (5) Started spirinolactone 25 mg daily blood pressure. (6) Stop benicar-HCTZ combination pill. (7) Stop labetolol. (8) go [Hospital3 ] [Hospital1 ] [Location (un) 620] [Location (un) 766] [6-10] get INR (coumadin level) checked. [Hospital3 271] call [Hospital3 766] morning confirm this. Followup Instructions: Primary Care: [Last Name (LF) ],[First Name3 (LF) ] -You need get blood checked [First Name3 (LF) 766] hospital: prescription get labwork done outpatient. -You appointment Dr [Last Name (STitle) 5419] on: Wed 16th 430 PM Phone: [Telephone/Fax (1) 31235] FAX [Telephone/Fax (1) 85534] . [Hospital3 271] [Hospital1 ] [Location (un) 620]: [Telephone/Fax (1) 41860]. Please go hospital registration ask directions [Telephone/Fax (1) 766] INR checked. . appointment Cardiology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2109-6-17] 12:40	[ "4019", "2449" ]
Admission Date: [2108-9-26] Discharge Date: [2108-10-5] Service: MEDICINE Allergies: Aspirin / Sulfa (Sulfonamides) / Codeine Attending:[First Name3 (LF) 2297] Chief Complaint: transfer MWH cardiac catheterization CP trops elevation 0.79, likely NSTEMI (non ST elevation myocardial infarction) Major Surgical Invasive Procedure: cardiac catheterization History Present Illness: 84yo male CAD - CABG x5 [2094] (LIM LAD, SVG DA, SVG [Female First Name (un) ], SVG PDA, SVG lt ventr branches), MI [2070], s/p AAA repair, s/p fem-[Doctor Last Name ] bypass, CRF HD transferred MWH cath ?dx MI. Patient initially presented MWH ED [2108-9-24] c/o continuous 7 10 shoulder shoulder chest pain radiation. denied SOB diaphoresis. Took nitro home x2 relief. ED, +Trop 0.79, EKG 100% paced, received iv nitro morphine, plavix heparin. aspirin given (as per GI) h/o severe GI bleed aspitrin. Pt 2 subsequent episodes CP overnight relieved Morphine. [9-26], pt transferred [Hospital1 18] cath. Past Medical History: CAD - MI [2070], CABG x5 [2094] [Hospital1 336] s/p AAA repair [2082] PPM [2105] Bilateral Fem-[Doctor Last Name ] Bypass CRF-HD T-Th-Sat (last dialysis [9-25], tolerated well) severe duodenal ulcer bleed [2105] - received 11 PRBC Chrone's Dx diverticulosis Social History: past tobacco Family History: . Physical Exam: PE: pt bed, looks comfortable, acute distress 98.7 BP 130/72, HR 60, RR 18, 96% R/A HEENT: symm neck, mouth clear, LN, flat JBP CHest: limited exam, clear, GAEB CVS: rrr, N S1S2, syst gr II-III/VI murm precordium [Last Name (un) ]: soft, N BS, NT Extrem: edema, varicose veins Pulses: normal carotid, radial, doplerable pedal Neuro: alert, oriented x3, grossly N Lt Groin: hematoma (4pm) Pertinent Results: [2108-9-26] 06:55PM CK-MB-30* MB INDX-13.8* cTropnT-0.89* [2108-9-27] 03:00AM CK-MB-129* MB Indx-20.4* [2108-9-27] 06:40AM CK-MB-155* MB Indx-20.9* cTropnT-2.54* [2108-9-26] 06:55PM WBC-7.1 RBC-3.25* HGB-11.4* HCT-33.7* MCV-104* MCH-35.0* MCHC-33.7 RDW-15.8* [2108-9-26] 06:55PM PLT SMR-NORMAL PLT COUNT-178 [2108-9-26] 06:55PM GLUCOSE-74 UREA N-52* CREAT-6.4* SODIUM-135 POTASSIUM-5.3* CHLORIDE-92* TOTAL CO2-21* ANION GAP-27* Cardiac cath:1. Coronary grft angiography showed previous right dominant system. LMCA diffusely disesed focal critical lesions. LAD tapered mid segment large S2 totally occluded. D1 D2 small vessels diffusely diseased. D3 recived SVG seen LMCA injection. Mid distal LAD receives LIMA. Cx vessel self lesions. gives lengthy collateral. OM1 arises close LMCA small. OM2 arises close LMCA large. proximal lesion 80%. OM3 recives SVG seen LMCA injection. OM4/postero latateral branch arises distally small vessel. RCA occluded proximally. distal RCA including PDA PLV collateralised left system. PDA poorly filled mid 60% lesion. LIMA , LIMA-LAD anastomosis distal LAD free disease. LIMA fills LAD retrogradely supply proximal LAD D3. D3 ostial 70% lesion TIMI III flow. SV grafts RCA PLB occluded completely seen stumps aorta. graft Diagonal could located, likely occluded given angiogaphic findings. SVG OM3 shows diffuse disease mid lengthy lesion 99 % whole vessel showed TIMI II flow. collaterals OM. 2. Left ventriculography performed. 3. Predilation using 1.5 X 15 Maverick balloon, stenting using 3.0 X 28 3.0 X 33 OTW Cypher stents thrombus extraction using export catheter gradual deterioration flow SVG OM3. flow deteriorated TIMI TIMI 0. FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease functioning LIMA LAD. 2. Acute occlusion SVG OM chronically occluded SV grafts PDA, PLB Diagonal. 3. Unable restore flow SVG OM despite stenting, pharmacotherapy thrombus aspiration. . Echo: . left atrium mildly dilated. 2. left ventricular cavity size normal. Overall left ventricular systolic function mildly depressed. Basal inferior hypokinesis present. 3. aortic valve leaflets severely thickened/deformed. moderate aortic valve stenosis. 4. mitral valve leaflets mildly thickened. 5. mild pulmonary artery systolic hypertension. . ct scan: 1. evidence intrahepatic gas suggested prior ultrasound. Repeat ultrasound suggested given change appearance. 2. Bibasilar dependent atelectatic changes/consolidation associated effusions. 3. Gas distended loops bowel air-fluid levels without transition suggesting ileus. Stool distended rectum. 4. Small infrarenal abdominal aortic aneurysm. Brief Hospital Course: admitted unstable angina, total occlusion svg grafts patent LIMA LAD, received 2 cypher stents. catheterization compicted failed thrombus extractuib abd TIMI 0. catherization persistent CP evidence NSTEMI. Initially treated ASA past GI bleed, persistent ischemia, added plavix. required significant morphine controll pain. discussions MICU team family pain control determined option him. code status changed DNR/DNI/. Due ongoing ischemia, persistent hypotension required multiple pressors. HD changed CVVH low blood presssure. also intermittent NSVT. transferred [Hospital Unit Name 196] team MICU team due hypotension HD cardiac catheterization concern possible sepsis. concern acute abdomen appeared impacted stool. disimpacted received aggresive bowel regimen. distension pain improved. low grade temperatures initially treated pneumonia hypoxic. source infection identified. likely cardiogenic shock fluid overload. repeat bedside echo reveal worsening ventricular function. required blood transfusions persistently dropping HCT setting frequent blood draws. also coagulopathy appear DIC. required vitamin K supplementation. expired 6:45am [2108-10-5] episode severe chest pain. Medications Admission: Plavix 300mg x2 [2078-9-24] mg [Hospital1 ] starting [2108-9-26] Lopressor 12.5mg [Hospital1 ] Foslo 667mg x4 TID Quinine 324mg daily Pentasa 250mg x4 QID MVI Mirtazapine 15mg qhs Colace 100mg [Hospital1 ] Protonix 40mg daily Morphine prn Nitro prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: sinus tachycardia nsvt cardiogenic shock coagulopathy obstipation nstemi esrd Discharge Condition: expired Discharge Instructions: . Followup Instructions: . Completed by:[2108-12-21]	[ "4280", "486" ]
Admission Date: [2108-4-4] Discharge Date: [2108-5-8] Date Birth: [2036-9-21] Sex: F Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) / Heparin Agents Attending:[First Name3 (LF) 32612] Chief Complaint: Painless jaundice. Major Surgical Invasive Procedure: [2108-4-4]: -Diagnostic laparoscopy. -Peritoneal washings cytology -Exploratory laparotomy. -Cholecystectomy. -Harvest pedicled omental flap protection anastomoses. -Pancreaticoduodenectomy standard gastrojejunostomy, antecolic. - Right hepatic artery reconstruction using right gonadal vein interposition graft (performed Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]). History Present Illness: 71F presented painless jaundice, dark urine, bloating, anorexia. first noticed onset symptoms [Month (only) ] [Month (only) 1096] alerted friend increasing jaundice, prompted medical evaluation. [Hospital3 3583], labs follows: total bilirubin 28, Alk phos 338, ALT 128 prior arrival. underwent ultrasound CT contrast found 2.4 x 1.8 cm mass cystic structre head pancreas, distended thickened gallbladder, intrahepatic (1.9 cm)and pancreatic duct (1.2 cm). time consultation clinically well denies nausea, vomiting, changes bowel habits. underwent ERCP revealed single irregular stricture malignant appearance 2 cm long lower third common bile duct. severe post-obstructive dilation. limited pancreatogram revealed stricture main duct head. Cannulation biliary duct successful. Contrast medium injected resulting complete opacification. sphincterotomy performed. 7cm 10FR biliary stent placed. Cytology samples obtained histology returned positive adenocarcinoma. patient offered Whipple operation, following explained: 1-2% risk death, 30-40% risk complication. OSH scan report, involvement mesenteric vessels evidence metastatic disease, although periportal lymphadenopathy. understood risks/benefits surgery, decided proceed operation. Past Medical History: PMH: None PSH: Tonsillectomy/adenoidectomy, teeth extracted Social History: Retired high school teacher, children, lives female HCP. [Name (NI) 4084] [Name2 (NI) 1818], drank [2-17] glasses wine per night symptoms started [Month (only) ]/[Month (only) ], drug use. Family History: Sister died leukemia age 65, mother died cervical cancer. history benign malignant pancreatic disease. Physical Exam: Physical Exam Admission: 97.3 91 173/94 20 100%RA Gen: Alert oriented, pleasant Skin: Pronounced scleral dermal jaundice CV: RRR Resp: Clear auscultation Abd: Soft, non-tender, non-distended. Negative [Doctor Last Name 515] sign, palpable masses Ext: 1+ edema, palp DP/PT pulses. Pertinent Results: [2108-4-12] 07:24AM BLOOD Vanco-31.4* [2108-5-8] 06:05AM BLOOD Vanco-12.4 [2108-4-4] 07:54PM BLOOD Albumin-2.1* Calcium-8.9 Phos-5.7# Mg-1.9 [2108-5-8] 01:56AM BLOOD Calcium-10.9 Phos-2.1* Mg-2.7* [2108-4-4] 07:54PM BLOOD CK-MB-2 cTropnT-<0.01 [2108-4-15] 12:58PM BLOOD CK-MB-2 cTropnT-0.03* [2108-4-5] 03:30AM BLOOD Lipase-13 [2108-5-7] 01:23AM BLOOD Lipase-7 [2108-4-4] 07:54PM BLOOD ALT-303* AST-827* CK(CPK)-57 AlkPhos-56 TotBili-5.7* [2108-4-18] 01:45AM BLOOD ALT-38 AST-80* AlkPhos-59 TotBili-32.4* DirBili-23.7* IndBili-8.7 [2108-5-2] 01:18AM BLOOD ALT-49* AST-82* AlkPhos-65 TotBili-36.9* [2108-5-8] 01:56AM BLOOD ALT-59* AST-94* LD(LDH)-202 AlkPhos-77 TotBili-33.6* [2108-4-4] 07:54PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-134 K-4.8 Cl-100 HCO3-15* AnGap-24* [2108-5-8] 01:56AM BLOOD Glucose-143* UreaN-4* Creat-0.5 Na-142 K-4.7 Cl-101 HCO3-9* AnGap-37* [2108-4-4] 08:12AM BLOOD Fibrino-515* [2108-4-5] 07:50PM BLOOD Fibrino-156# [2108-4-4] 08:12AM BLOOD PT-12.3 PTT-27.8 INR(PT)-1.1 [2108-4-6] 03:48AM BLOOD Plt Ct-139 [2108-4-7] 11:55PM BLOOD Plt Smr-VERY LOW Plt Ct-62* [2108-4-12] 02:57AM BLOOD Plt Ct-56# [2108-5-7] 08:15PM BLOOD Plt Ct-<5 [2108-5-8] 01:56AM BLOOD PT-49.9 PTT-122.1* INR(PT)-4.9* [2108-4-7] 11:55PM BLOOD Neuts-86* Bands-3 Lymphs-4* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1* [2108-5-6] 02:16AM BLOOD Neuts-90* Bands-1 Lymphs-2* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 Promyel-1* [2108-4-4] 07:54PM BLOOD WBC-14.6# RBC-2.58 Hgb-8.2* Hct-24.1* MCV-93# MCH-31.7# MCHC-34.0 RDW-16.5* Plt Ct-88* [2108-4-5] 07:50PM BLOOD WBC-26.4# RBC-3.07 Hgb-9.7* Hct-28.4* MCV-93 MCH-31.7 MCHC-34.2 RDW-16.3* Plt Ct-102* [2108-4-7] 05:41AM BLOOD WBC-28.5* RBC-3.23* Hgb-9.7* Hct-29.7* MCV-92 MCH-30.0 MCHC-32.6 RDW-16.0* Plt Ct-93* [2108-4-9] 12:49PM BLOOD WBC-16.4* RBC-3.05* Hgb-9.5* Hct-28.8* MCV-95 MCH-31.3 MCHC-33.0 RDW-18.0* Plt Ct-43* [2108-5-7] 08:15PM BLOOD WBC-41.4* RBC-2.19* Hgb-7.5* Hct-23.7* MCV-108* MCH-34.3* MCHC-31.7 RDW-22.5* Plt Ct-<5 [2108-5-7] 10:15PM BLOOD WBC-48.1* RBC-2.26* Hgb-7.7* Hct-24.9* MCV-110* MCH-34.1* MCHC-31.0 RDW-22.8* Plt Ct-88* [2108-5-8] 01:56AM BLOOD WBC-47.3* RBC-2.21* Hgb-7.7* Hct-24.5* MCV-115* MCH-34.7* MCHC-30.2* RDW-23.0* Plt Ct-72* . [2108-4-9] 11:46 SPUTUM Source: Endotracheal. GRAM STAIN (Final [2108-4-9]): >25 PMNs <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2108-4-12]): Commensal Respiratory Flora Absent. HAFNIA ALVEI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available request. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ HAFNIA ALVEI \| AMPICILLIN------------ 16 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CIPROFLOXACIN---------<=0.25 GENTAMICIN------------ <=1 MEROPENEM-------------<=0.25 TOBRAMYCIN------------ <=1 TRIMETHOPRIM/SULFA---- <=1 . [2108-5-1] 5:55 PERITONEAL FLUID DAS ACU VERIFIED [First Name9 (NamePattern2) 92514] [Location (un) ] [5-1] @0950. GRAM STAIN (Final [2108-5-1]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. concentrated smear made cytospin method, please refer hematology quantitative white blood cell count.. FLUID CULTURE (Final [2108-5-5]): Reported read back [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2108-5-2] 2:45PM 4-3130. culture contains mixed bacterial types (>=3) abbreviated workup performed. growth P.aeruginosa, S.aureus beta hemolytic streptococci reported. BACTERIA REPORTED BELOW, PRESENT culture.. Work-up organism(s) listed discontinued (excepted screened organisms) due presence mixed bacterial flora detected incubation. ENTEROCOCCUS SP.. RARE GROWTH. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 ANAEROBIC CULTURE (Final [2108-5-5]): ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. ACID FAST SMEAR (Final [2108-5-2]): ACID FAST BACILLI SEEN DIRECT SMEAR. ACID FAST CULTURE (Preliminary): MYCOBACTERIA ISOLATED. . [2108-5-6]: [2108-5-6] 10:54 URINE Source: Catheter. FINAL REPORT [2108-5-7] URINE CULTURE (Final [2108-5-7]): YEAST. >100,000 ORGANISMS/ML.. . [2108-4-12]: IMPRESSION: Non-occlusive deep vein thrombosis seen within one two left brachial veins . [2108-4-16]: IMPRESSION: 1. Status post Whipple serpiginous hypodensity seen left lobe consistent retraction injury. drainable collection. 2. radiologically evident cause leukocytosis observed. 3. Extensive anasarca, likely secondary volume overload. . Final Pathology Report: MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head, uncinate process. Tumor Size: Greatest dimension: 2.9 cm. Additional dimensions: 2.5 cm x 2.5 cm. organs/Tissues Received: Gallbladder, Stomach. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT INVASION Primary Tumor: pT3: Tumor extends beyond pancreas without involvement celiac axis superior mesenteric artery. Regional Lymph Nodes: pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 11. Number involved: 1. Distant metastasis: pMX: Cannot assessed. Margins: Margins uninvolved invasive carcinoma: Distance closest margin: 1 mm peri-uncinate-process adipose tissue margin. Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Additional Pathologic Findings: Pancreatic intraepithelial neoplasia -- highest grade: PanIN: III; chronic pancreatitis. . Brief Hospital Course: patient brought operating room [2108-4-4] Whipple procedure, necessitating right hepatic artery reconstruction gonadal vein vascular surgery service consulted intraoperatively. Reader referred operative notes full details. received 6 u pRBC, 2 FFP, 500 albumin OR, left intubated pressors, taken surgical ICU post operatively. course thereafter ICU complicated. brief: required frequent blood transfusions pRBCs, FFP, albumin, persistent pressor requirement; developed acute renal failure requiring CVVH, persistent elevations LFTs, persistent leukocytosis total cardiology, infectious disease, renal, hepatology services consulted. Significant events post-operative day included: POD2 renal service consulted given persistent renal failure postoperatively, begun CVVH. Given down-trending platelets, HIT panel sent returned positive POD5, patient begun bivalirudin drip per hematology recommendations. POD6 TF initiated via NGT, foley removed, sputum cultures revealed GNR begun vancomycin/ciprofloxacin/flagyl. Antibiotics thereafter tailored appropriately consultation infectious disease service. POD8 left brachial vein clot found non-invasives initiated fondaparinux, subsequently discontinued. POD11 patient noted QTC prolongation, cardiology service consulted, recommendations followed regarding medication adjustments. [2108-4-17] patient extubated, briefly pressors. found SBP, begun meropenem consultation hepatology ID services. Lactulose initiated given poor mental status (AOx1 initially), seemed initially improve. POD20 patient failed speech swallow evaluation, continued tube feedings. pressor requirement remained persistent, WBC continued trend upwards. [2108-5-4], discussion patient's HCP, made DNR/DNI. evening [2108-5-7] noted hypothermic 89, DIC per labarotory values passed away [2108-5-8], post-operative day 34. Discharge Disposition: Expired Discharge Diagnosis: -Pancreatic cancer -Spontaneous bacterial peritonitis -Heparin Induced Thrombocytopenia -Renal failure Discharge Condition: Expired. Discharge Instructions: N/A. Followup Instructions: N/A. Completed by:[2108-5-9]	[ "2851", "4019" ]
Admission Date: [2118-5-7] Discharge Date: [2118-5-19] Date Birth: [2047-9-30] Sex: Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2698] Chief Complaint: Chest pain anemia Major Surgical Invasive Procedure: Colonoscopy Upper Endoscopy History Present Illness: 70 year old man afib coumadin, insulin dependent DM, obseity, systolic diastolic heart failure LVEF 40-45%, CAD s/p CABG '[93], PTCA'[15], STEMI BMS SVG-OM graft [2118-4-8], presents fatigue dyspnea exertion past week. initially feeling well discharge [3-/2117] began exercising losing weight. However, past week dyspnea increased exertional capacity decreased. called cardiologist thought might overdiuresed, therefore lasix spironolactone reduced half prior doses. Dyspnea worsened despite change. day admission 2 bowel movements, second dark black. bowel movement preceeded crampy abdominal pain. attempted walk bathroom kitchen acutely dyspneic. sat developed chest pain, took nitro relief. Tried walk chest pain returned, thus called EMS brought OSH. chest pain relieved repeated nitroglycerin eventually started nitroglycerin drip. Labs OSH notable HCT 25, INR 3.7, K 7. Enroute [Hospital1 18], SBP dropped increasing nitro drip doses. Upon arrival [Hospital1 18], chest pain free VS 97.6 99/56, 74 16 97% 2L. ECG showed new LBBB, trop negative. Labs notable K 7.2 (not hemolyzed) thus received calcium, D50/insulin, kayexalate. INR 4.9. GI called given HCT drop 31 25 made plans scope morning. Rectal exam notable brown stool guaiac positive specks black stool. Nitroglycerin drip stopped pain controlled morphine PRN. received 1L NS. Vitals prior transfer 98.1 69 109/41 16 99% RA pain 0. arrival MICU, initially comfortable, developed chest pain prompting morphine 2mg x3 without relief. SL nitro given improvement pain. ECG showed narrow complex sinus rhythm ST depressions I, V4-V6. later another episode pain relieved SL nitroglycerin. Past Medical History: CAD s/p CABG [2093], s/p cath [2103] wiuth BMS Lcx, [2113] revealing severe stenosis SVG OM s/p BMS x 3, [2115] [Hospital1 112] (patient says stent unknown location) IDDM morbid obesity COPD sleep apnea BiPAP CHF, diastolic, EF 71% per OSH reports afib HTN CVA right sided numbness history rheumatic fever Social History: Lives wife four children. Worked carpenter. tob/ETOH/IVDA. Family History: Adopted, unknown Physical Exam: Admission exam: Vitals: 98F 108/44 71 9 99% RA General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated, LAD CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge exam: VS - 98.0, 98.6, 96/49 (94-145/48-71), 71 (52-81), 20, 100RA GENERAL - Obese late-middle aged man NAD. Oriented x3. HEENT - NCAT. Oropharynx clear NECK - Supple, unable assess JVD due habitus CARDIAC - RRR, normal S1, S2. m/r/g. S3 S4. LUNGS - CTAB, crackles, wheezes rhonchi. ABDOMEN - Soft, obese NTND. HSM tenderness. EXTREMITIES - WWP, LE edema, clubbing SKIN - Multiple scars across lower extremities vein harvesting, chronic stasis changes Pertinent Results: Admission Labs: =============== [2118-5-6] 11:55PM BLOOD WBC-11.2* RBC-2.82* Hgb-8.0* Hct-24.7* MCV-87 MCH-28.3 MCHC-32.3 RDW-19.2* Plt Ct-178 [2118-5-6] 11:55PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.0 Eos-1.3 Baso-0.2 [2118-5-6] 11:55PM BLOOD PT-49.3* PTT-56.2* INR(PT)-4.9* [2118-5-6] 11:55PM BLOOD Glucose-187* UreaN-78* Creat-1.9* Na-131* K-7.2* Cl-99 HCO3-22 AnGap-17 [2118-5-7] 03:20AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.6 Pertinent Labs: =============== [2118-5-6] 11:55PM BLOOD cTropnT-<0.01 [2118-5-7] 03:20AM BLOOD CK-MB-4 cTropnT-0.02* [2118-5-7] 08:55AM BLOOD CK-MB-5 cTropnT-0.04* [2118-5-7] 10:58PM BLOOD CK-MB-4 cTropnT-0.05* [2118-5-12] 10:50AM BLOOD Hapto-164 [2118-5-12] 10:50AM BLOOD LD(LDH)-195 TotBili-2.0* DirBili-0.5* IndBili-1.5 HELICOBACTER PYLORI ANTIBODY TEST: POSITIVE EIA. Urine culture [5-9]- growth Discharge Labs: =============== [2118-5-19] 06:35AM BLOOD Hct-29.5* [2118-5-17] 11:00AM BLOOD PT-11.9 PTT-33.3 INR(PT)-1.1 [2118-5-18] 11:10AM BLOOD Glucose-108* UreaN-21* Creat-1.1 Na-136 K-4.6 Cl-100 HCO3-28 AnGap-13 [2118-5-18] 11:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2* Micro/Path: =========== URINE CULTURE (Final [2118-5-10]): GROWTH. HELICOBACTER PYLORI ANTIBODY TEST (Final [2118-5-9]): POSITIVE EIA. MRSA SCREEN (Final [2118-5-9]): MRSA isolated. Imaging/Studies: ================ CXR [5-9]- Status post sternotomy, mild prominence cardiomediastinal silhouette. upper zone re-distribution without overt CHF. minimal atelectasis bases. frank consolidation effusion. EKG [5-9]- LBBB -> sinus rhythm narrow complex, ST depressions V4-V6 I, avL EGD [5-9]- Nodularity whole stomach compatible nodular gastritis. Normal EGD third part duodenum. CT abd/pelvis [5-12]- 1. evidence retroperitoneal bleed acute intra-abdominal process. 2. Fatty infiltration liver. 3. Cholelithiasis. 4. Right renal cyst. Colonoscopy [2118-5-18]: Impression: Grade 1 internal hemorrhoids Diverticulosis sigmoid colon Otherwise normal colonoscopy cecum Brief Hospital Course: 70 year old man afib coumadin, insulin dependent DM, obseity, systolic diastolic heart failure LVEF 40-45%, CAD s/p CABG '[93], PTCA'[15], STEMI BMS SVG-OM graft [2118-4-8], presents fatigue dyspnea exertion, found hematocrit drop secondary GI bleed. ACTIVE DIAGNOSES: ================= # Chest Pain: Demand ischemia setting GI bleed. known coronary vascular disease refractory angina amenable intervention per cardiology team. evidence consolidation PTX CXR suggest pulmonary cause. Patient transfused total 8 units pRBCs; hematocrit initially stabilized heparin gtt coumadin re-started, hematocrit dropped chest pain returned without EKG changes. continued aspirin, plavix, ranolazine. Imdur started lower dose home dose given concern hypotension setting bleeding, BP remained stable imdur titrated home dose. return chest pain, dynamic ST changes V3-V5 I/avL, consistent known non-intervenable areas disease. imdur increased 240mg metoprolol increased tartrate 150mg PO BID without episodes chest pain. # UGIB/H.Pylori + Nodular Gastritis: EGD, patient evidence nodular gastritis superficial erosions. H.pylori returned positive patient began triple therapy amoxicillin (not candidate clarithromycin given interaction ranolazine), metronidazole pantoprazole. Coumadin held INR reversed vitamin K. Patient ongoing hematocrit drop without obvious bleeding heparin drip restarted, coumadin heparin stopped. Patient complete 2 weeks triple therapy, continue [Hospital1 ] pantoprazole. require GI follow-up test cure. also underwent colonoscopy reveal additional alternative source bleeding. continues bleed, next step would capsule endoscopy. [Hospital1 ] check prior PCP appointment assess hematocrit. # Acute blood loss anemia: Source suspected gastritis above. Coumadin held admission ICU reversed vitamin K FFP. transfused total 8 units admission; initially 4 units ICU inappropriate response blood, floor initiation coumadin bridge heparin drip, patient's hematocrit drifted down. Haptoglobin LDH normal, indirect bilirubin slightly elevated (and post transfusion) low suspicion hemolysis. discontinuation heparin drip coumadin, hematocrit stabilized patient require transfusion >72 hours prior discharge. # Constipation: Significantly constipated admission. Required 2 days prep prior colonoscopy. Patient discharged senna/colace/miralax prevent constipation. # Acute chronic systolic heart failure: admission, patient mild pulmonary edema secondary decreased lasix spironolactone dose past week prior admission. Patient diuresed ICU, euvolemic transfer floor. continued home lasix 40mg daily, extra doses transfusions. episodes orthostatic hypotension prompting decrease lasix dose 20mg PO daily. Patient euvolemic time discharge, weight stable 120 kg. # Hyperkalemia: 7.2 admission likely secondary ARF, spironolactone, lisinopril. ECG improved narrow complex potassium normalized. Potassium remained stable remainder admission. Spironolactone restarted, lisinopril restarted lower dose 5mg PO daily. # LBBB: Suspect metabolic etiology given improved K correction. Trop negative suggesting acute coronary syndrome. LBBB resolved correction K. # Acute renal failure: Likely secondary systolic CHF poor forward flow second hit poor perfusion due acute GIB. Patient's creatinine trended 1.1 day discharge. # Leukocytosis: Unclear etiology, may due stress GIB. evidence infectious colitis, UA without evidence infection consolidation seen CXR. White count resolved remained normal remainder admission. CHRONIC DIAGNOSES: ================== # HLD: continued atorvastatin # Depression: continued venlafaxine # DMII: Blood sugar well controlled admission. Transitional issues: # Spironolactone held discharge given hyperkalemia 7.2 admission. # Coumadin held discharge -> anticipate holding medication month gastritis heals protection stroke aspirin 325mg plavix 75mg interim. # Lisinopril decreased 5mg daily prevent hyperkalemia increase pressure room uptitrate Imdur 240mg PO daily metoprolol 150mg tartrate [Hospital1 ] # H.pylori triple therapy treatment continue [2118-5-23] # Hematocrit electrolytes rechecked PCP [Name9 (PRE) 702] appointment, script this. # Insulin decreased 70/30 mix 80 units daily given in-house hypoglycemia. suggest setting [Last Name (un) ] diabetes management wanted discuss PCP [Name Initial (PRE) ]. # Weight discharge 120kg, discharged furosemide 20mg daily. Medications Admission: 1. aspirin 325 mg DAILY 2. nitroglycerin 0.4 mg q5min PRN 3. furosemide 40 mg PO daily 4. lisinopril 10 mg PO DAILY 5. atorvastatin 80 mg PO DAILY 6. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: One Hundred (100) units Subcutaneous twice day. 7. metformin 500 mg PO daily 8. venlafaxine 75 mg PO DAILY 9. warfarin 5 mg PO day. 10. pantoprazole 40 mg PO day. 12. ranolazine 1,000 mg PO twice day. 13. clopidogrel 75 mg PO daily 14. isosorbide mononitrate 60 mg PO day. 15. metoprolol succinate 200 mg PO day. 16. spironolactone 25 mg PO day. Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO BID (2 times day). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [Name Initial (PRE) ]:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) needed chest pain. 7. metformin 500 mg Tablet Sig: One (1) Tablet PO day. 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) 4 days. [Name Initial (PRE) ]:12 Tablet(s) Refills:0 9. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice day 4 days. [Name Initial (PRE) ]:16 Tablet(s) Refills:0 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed Constipation. [Name Initial (PRE) ]:30 Tablet(s) Refills:0 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). [Name Initial (PRE) ]:30 Capsule(s) Refills:2 12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day. 13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO twice day. [Name Initial (PRE) ]:180 Tablet(s) Refills:2 14. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Eighty (80) units Subcutaneous twice day. 15. Imdur 60 mg Tablet Extended Release 24 hr Sig: Four (4) Tablet Extended Release 24 hr PO day. 16. Miralax 17 gram Powder Packet Sig: One (1) PO day. [Name Initial (PRE) ]:30 packets Refills:2 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO day. [Name Initial (PRE) ]:30 Tablet(s) Refills:0 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO day. [Name Initial (PRE) ]:30 Tablet(s) Refills:0 19. Outpatient [Name Initial (PRE) ] Work Please obtain CBC, Chem 7 prior appointment. results communicated PCP: [Name Initial (NameIs) 7274]: [Name Initial (NameIs) ],[Name Initial (NameIs) ] Address: [Hospital1 29147], [Location (un) ],[Numeric Identifier 29160] Phone: [Telephone/Fax (1) 29149] Fax: [Telephone/Fax (1) 29155] Discharge Disposition: Home Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnosis: # Unstable Angina # H. pylori + nodular gastritis erosions # Blood loss anemia Secondary diagnosis: # Coronary artery disease # Atrial Fibrillation Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (rolling walker) Discharge Instructions: Dear Mr. [Known lastname ], pleasure taking care you! admitted [Hospital1 18] evaluation treatment chest pain, shortness breath, GI bleeding. found low blood count likely due slow bleed GI tract related blood thinners gastritis erosions H. pylori (a bacteria pre-disposes gastritis ulcers). started medication protect GI tract, treatment infection, given blood transfusions improve blood counts. underwent upper endoscopy showed inflammation stomach erosions colonoscopy without source bleeding. also elevation potassium level, spironolactone discontinued. attempted re-starting anticoagulation began bleed again. result, coumadin held resolution gastritis. suggesting waiting month resuming coumadin would like re-assure recieving protection stroke afib aspirin plavix. following changes made medication regimen: - START Metronidazole three times day Monday [2118-5-23] treat infection stomach - START Amoxicillin twice day Monday [2118-5-23] treat infection stomach - INCREASE pantoprazole twice day protect stomach lining - INCREASE Imdur 240mg mouth daily - CHANGE Metoprolol Tartrate 150mg mouth twice daily - DECREASE Lisinopril 5mg daily - DECREASE Lasix 20mg daily - DECREASE Insulin 70/30 80 units twice daily - STOP Spironolactone - STOP Coumadin -> discuss primary care doctor restarting medication month gastritis healed - START Senna Colace twice day needed constipation - START Miralax daily needed constipation Please follow suggested below. Followup Instructions: Name:[Name6 (MD) ] [Name8 (MD) ],MD Specialty: Primary Care Address: [Hospital1 29147], [Location (un) ],[Numeric Identifier 29160] Phone: [Telephone/Fax (1) 29149] When: Tuesday, [5-24] 3:15pm -Please labs checked prior appointment, discharge hematocrit 29.5 Department: CARDIAC SERVICES When: THURSDAY [2118-5-26] 9:40 With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2118-5-20]	[ "5849", "4280", "2851", "4019" ]
Admission Date: [2146-5-11] Discharge Date: [2146-5-14] Date Birth: [2068-2-6] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 458] Chief Complaint: Shortness breath Major Surgical Invasive Procedure: Cardiac catheterization Drug eluting stent Right coronary Artery History Present Illness: 78 year-old male patient Dr. [First Name (STitle) 28622] Attar Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493] history includes CAD, s/p MI X 2, s/p CABG [2139], s/p prior stent LAD s/p prior PTCA diagonal admitted [Hospital6 17032] [2146-5-7] shortness breath. diagnosed acute chronic CHF initial BNP 482. diuresed IV Lasix ruled MI negative cardiac enzymes. nuclear stress performed [5-9] showed several areas questionable reversible inferolateral anteroapical ischemic changes EKG changes chest pain. believed heart rate response blunted [2-14] high dose BBlocker deconditioning. overall duration treadmill time 5 minutes heart rate max 81 bpm. discharged home returned [Location (un) ] ED continued complaints shortness breath. Cardiac enzymes negative transferred cardiac cathterization evaluation symptoms. cath lab, pt unable lie flat secondary history PTSD, claustrophia, anxiety therefore required intubation. 90% distal lesion, beyond PDA stented [Location (un) ]. end procedure, NGT placed dose plavix. Pt already started integrelin heparin. Subsequently, patient developed significant nose bleed. Heparin integrelin held, ENT called, pressure held patient given intranasal afrin. Right heart cath also notable elevated RVEDP (16 mm Hg) PCWP (28 mm Hg mean). Past Medical History: Coronary Artery Disease s/p CABG [2139] (LIMA->diag, SVG->OM1, SVG->LAD) s/p Myocardial Infarction X 2 s/p prior LAD stent PTCA diag Chronic systolic heart failure [2-14] ischemic cardiomyopathy, last known EF 20% Ischemic cardiomyopathy, s/p ICD implantation [2141-7-14] Type 2 Diabetes Mellitus, insulin-dependent Chronic Obstructive Pulmonary Disease, home O2 requirement Hypertension Hyperlipidemia Diabetic Nephropathy/Chronic Renal Insufficiency Diabetic Neuropathy s/p right renal artery stent Severe Peripheral Vascular Disease, s/p left fem-[Doctor Last Name ] bypass [2137] GERD Anxiety Depression Post Traumatic Stress Disorder Paroxysmal Atrial Fibrillation Nonsustained Ventricular Tachycardia Social History: Married lives wife. Retired Army. recently worked cook [Hospital ] [Hospital6 28623]. used drink alcohol heavily, none 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died MI age 48. Brother died MI age 64. Physical Exam: Vitals: 129/48 - 67 - 17 - 100% room air Neuro: Alert, oriented person, place, time. Hard hearing. Cardiac: Regular rate rhythm. Normal S1,S2. murmurs/rubs/gallops. Resp: Lungs fine crackles bases bilaterally. Breathing regular unlabored rest. Periph vasc: Bilateral femoral pulses palpable. Bilateral DP PT pulses palpable. 1+ pedal edema bilaterally. ECG: SR 73 PVC's Pertinent Results: Admission labs: [2146-5-11] 09:52PM BLOOD WBC-9.5# RBC-4.34* Hgb-13.3* Hct-39.0* MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-280 [2146-5-11] 09:52PM BLOOD Neuts-76.0* Lymphs-13.9* Monos-6.5 Eos-3.2 Baso-0.4 [2146-5-11] 09:52PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2* [2146-5-11] 09:52PM BLOOD Glucose-264* UreaN-29* Creat-1.6* Na-134 K-4.6 Cl-99 HCO3-27 AnGap-13 [2146-5-11] 09:52PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.4 . Cardiac cath ([5-13]): 1. Coronary angiography right dominant system revealed native three vessel coronary artery disease. LMCA distal 50% stenosis. LAD occluded mid-vessel. major diagonal branch ostial 60% stenosis. LCx long 60% lesion OM1. RCA 90% stenosis beyond origin PDA. 2. Arterial conduit angiography demonstrated patent LIMA-D1 SVG-OM grafts. SVG-OM occluded proximally. 3. Resting hemodynamics revealed elevated right left sided filling pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). moderate severe pulmonary arterial hypertension (PASP 61 mm Hg). systemic arterial blood pressure normal (SBP 122 mm Hg). cardiac index normal 2.7 l/min/m2. systemic vascular resistance normal (911 dynes-sec/cm5). pulmonary vascular resistance normal (PVR 135 dynes-sec/cm5). 4. Successful PTCA stenting distal RCA jailing right PDA Xience (3x18mm) drug eluting stent postdilated 3.25mm balloon. Final angiography demonstrated angiographically apparent dissection, residual stenosis TIMI III flow throughout vessel (See PTCA comments). 5. Successful closure right femoral arteriotomy site Mynx closure device. FINAL DIAGNOSIS: 1. Native three vessel coronary artery disease. 2. Patent LIMA-D1 SVG-LAD grafts. 3. Occluded SVG-OM graft. 4. Moderate biventricular diastolic dysfunction. 5. Moderate pulmonary hypertension. 6. Successful PTCA stenting distal RCA Xience drug eluting stent. 7. Successful closure right femoral arteriotomy site Mynx closure device. . Discharge labs: [2146-5-14] 07:41AM BLOOD WBC-8.8 RBC-4.17* Hgb-12.7* Hct-36.9* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt Ct-275 [2146-5-14] 07:41AM BLOOD Glucose-206* UreaN-31* Creat-1.6* Na-137 K-4.1 Cl-99 HCO3-25 AnGap-17 [2146-5-14] 07:41AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.4 Brief Hospital Course: 78 year-old man referred OSH cardiac catheterization secondary persistent shortness breath. # Coronary Artery Disease - Patient known hx CAD, prior CABG, prior stent/PTCA referred cardiac ctah persistent shortness breath. Patient tolerate lying flat procedure due significant history claustrophobia, PTSD anxiety intubated procedure. started heparin, integrillin plavix loaded pre-procedure however developed severe epistaxis intubation integrilin stopped. Cardiac cath showed distal 90% RCA lesion [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] placed. continued aspirin, plavix statin. cath, remained intubated airway protection epistaxis nad admitted CCU closer management. extubated hospital day #2 without complication. . # Chronic systolic heart failure - Ischemic cardiomyopathy, EF 20%. RHC notable elevated RVEDP (16 mm Hg) PCWP (28 mm Hg mean). catheterization diuresed bolus lasix home dose lasix increased 100mg [Hospital1 ]. continued Inspra, Diovan Toprol. time discharge exam notable lower extremity edema, patient evidence pulmonary edema oxygen requirement instructed continue higher dose lasix could discuss lasix titration cardiologist outpatient. . # Epistaxis - Developed cardiac catheterization ENT consulted. managed Afrin. Estimated blood loss 200cc stabilized without tranfusion. resolved within 24 hours recurrent events. . # Hypertension: continued home [Hospital1 4319] Lasix, Diovan, Norvasc, Inspra Toprol good control . # Hyperlipidemia: recent lipid panel. admission tricor statin added regimen. . # Type II Diabetes, Insulin-Dependent: continued home regimen basal-bolus insulin good control. changed amde insulin regimen admission. . # Stage 3 chronic renal failure - Baseline Cr 1.8, received pre-cath hydration mucomyst creatinine remained stable contrast load procedure. . # Depression: Mood stable admission . Patient currently pharmacological treatment depression. Medications Admission: Flonase 50 mcg one spray nostril daily Proventil inhaler two puffs four times daily prn shortness breath wheezing Tricor 145 mg one tab daily Lasix 80 mg twice day (reduced time d/c NVMC prior dose 120 mg [Hospital1 ]) Aspirin 325 mg one tab daily Imdur 30 mg one tab daily Insulin 70/30 60 units subcutaneous injection breakfast Insulin 50/50 60 unit subcutaneous injection dinnertime Levemir 37 units subcutaneous injection bedtime Diovan 40 mg one tab daily (recently added Dr. [Last Name (STitle) 11493] Inspra 25 mg one tab daily Norvasc 2.5 mg one tab daily Toprol XL 200 mg one tab daily (added NVMC) Plavix 75 mg one tab daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours needed shortness breath wheezing. 5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. 7. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: Sixty (60) units Subcutaneous twice day. 8. Levemir 100 unit/mL Solution Sig: Thirty Seven (37) units Subcutaneous bedtime. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Diovan 40 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 11. Tricor 145 mg Tablet Sig: One (1) Tablet PO day. 12. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times day). Disp:150 Tablet(s) Refills:2 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Epistaxis Post Traumatic Stress Syndrome Discharge Condition: stable. Discharge Instructions: cardiac catheterization drug eluting stent placed right coronary artery. need take Plavix every day one year. miss [First Name (Titles) 691] [Last Name (Titles) 4319] stop taking Plavix unless Dr. [Last Name (STitle) 11493] tells to. lifting 10 pounds 1 week. baths pools one week. may shower take dressing groin. procedure intubated breathing machine. nose bleed caused blood thinners needed Afrin sprayed nose stop bleeding. fever antibiotics short time. chest X-ray show pneumonia antibiotics discontinued. Weigh every morning, [Name8 (MD) 138] MD weight > 3 lbs 1 day 6 pounds 3 days. Adhere 2 gm sodium diet . Please call Dr. [Last Name (STitle) 11493] notice increased trouble breathing, chest pain, nausea, light headedness, increased bruising bleeding groin region, increasing coughs, fevers concerning symptoms. Followup Instructions: Primary Care: ATTAR,[Female First Name (un) ] Phone: [Telephone/Fax (1) 24306] Date/time: please call get home appt [1-14] weeks. Cardiology: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 11767] Date/Time:Friday [6-10] 1:00pm Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 11767] Date/Time:[2146-8-5] 11:20 Completed by:[2146-5-16]	[ "4280", "2724" ]
Admission Date: [2179-12-13] Discharge Date: [2179-12-23] Date Birth: [2107-1-5] Sex: F Service: CARDIOTHORACIC SURGERY CHIEF COMPLAINT: Shortness breath exertion. HISTORY PRESENT ILLNESS: patient 72history woman history hypertension, hyperlipidemia, congestive heart failure, rheumatic heart disease paroxysmal atrial fibrillation, admitted [Hospital6 1760] [2179-10-22], cardioversion rapid atrial fibrillation. admission, transesophageal echocardiogram showed ejection fraction 60% 1+ aortic insufficiency, 2+ mitral regurgitation, 2+ tricuspid regurgitation, small pleural cardiac effusion. echocardiogram unchanged previous echocardiogram [2179-7-11]. underwent cardiac catheterization [11-19] anticipation future cardiac surgery. catheterization showed left main 30%, left anterior descending 70%, circumflex 30%, OM1 70%, right coronary artery 50%. Please see catheterization report full details. admitted [2179-12-13], directly Operating Room coronary artery bypass grafting mitral valve replacement postoperative admission. PAST MEDICAL HISTORY: Rheumatic heart disease, congestive heart failure, hypertension, hypercholesterolemia, paroxysmal atrial fibrillation. PAST SURGICAL HISTORY: Right upper lobectomy nonsmall cell cancer [2179-8-10]. Bilateral cataract surgery. SOCIAL HISTORY: lives alone. patient 30 pack-year tobacco history. quit 15 years ago. Alcohol use occasional. ALLERGIES: KNOWN DRUG ALLERGIES. MEDICATIONS ADMISSION: Toprol XL 25 mg q.d., Amiodarone 200 mg b.i.d., Aspirin 325 mg q.d., Lipitor 200 mg q.d., Levothyroxine 112 mcg q.d., Coumadin 4 mg q.d., Protonix 40 mg q.d., Lisinopril 10 mg q.d. PHYSICAL EXAMINATION: General: patient frail-appearing woman acute distress. Skin: breaks rashes. HEENT: Pupils equal, round reactive light. Extraocular movements intact. Oropharynx clear. Upper dentures intact. Neck: Supple. jugular venous distention. bruits. Lungs: Clear auscultation bilaterally. well-healed lobectomy scar right. Heart: Regular, rate rhythm. 2/6 systolic ejection murmur. Abdomen: Obese, soft, nontender, nondistended hepatosplenomegaly. Extremities: clubbing, cyanosis, edema. patient bilateral lower extremity spider veins. Neurological: patient alert oriented times three. Pulses: Grossly intact pulses. Radial 2+ bilaterally, dorsalis pedis 2+ bilaterally, posterior tibial 1+ bilaterally, femoral 2+ bilaterally. Carotids identified. HOSPITAL COURSE: stated previously, patient direct admission operating room. [12-13], underwent mitral valve replacement coronary artery bypass grafting; please see operative report full details. summary, patient mitral valve replacement #25 Mosaic coronary artery bypass grafting times two, LIMA left anterior descending, saphenous vein graft obtuse marginal. tolerated operation well. Cardiopulmonary bypass time 224 min, cross-clamp time 181 min. transferred Operating Room Cardiothoracic Intensive Care Unit. time transfer, Milrinone 0.5 mcg/kg/min, Propofol 20 mcg/kg/min, Neo-Synephrine 3 mcg/kg/min. Additionally patient epinephrine Nitroglycerin drips dose identified time. patient well immediate postoperative period. anesthesia reversed. allowed awaken initially resedated neurological check. epinephrine drip weaned shortly arrival Cardiothoracic Intensive Care Unit. cardioactive medications titrated tolerated patient's hemodynamics throughout night operative date. postoperative day #1, patient's sedation discontinued. weaned ventilator successfully extubated. Milrinone weaned off. Neo-Synephrine weaned 0.25 mcg/kg/min. Additionally, Nitroglycerin drip maintained 0.25 mcg/kg/min. patient remained hemodynamically stable throughout postoperative day #1 2. postoperative day #3, cardioactive intravenous medications weaned transitioned oral medications. patient's chest tubes discharge, transferred Cardiothoracic Intensive Care Unit Far Two continued postoperative care cardiac rehabilitation. next several days, patient uneventful hospital course exception intermittent atrial fibrillation treated Amiodarone beta-blockade. Additionally patient restarted anticoagulation, receiving preoperatively atrial fibrillation. assistance nursing staff Physical Therapy staff, patient's activity level increased. postoperative day 8, decided patient stable would ready discharge home following day. DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature 98.2??????, heart rate 72, sinus rhythm, blood pressure 108/64, respirations 18, oxygen saturation 98% room air. Weight preoperatively 58.5 kg, discharge 54.8 kg. General: patient alert oriented times three. moved extremities. followed commands. Nonfocal exam. Chest: Clear auscultation bilaterally. Sternum stable. Incision Steri-Strips, open air, clean dry. Heart: Regular, rate rhythm. S1 S2. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Extremities: Warm well perfused. patient 1+ edema bilaterally. Right saphenous vein graft site Steri-Strips large echymotic area upper thigh. DISCHARGE LABORATORY DATA: Sodium 138, potassium 4.2, BUN 21, creatinine 1.0; PT 13, INR 1.0. CONDITION DISCHARGE: Good. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times two LIMA left anterior descending, saphenous vein graft obtuse marginal. 2. Mitral regurgitation status post mitral valve replacement #25 mosaic valve. 3. Rheumatic heart disease. 4. Congestive heart failure. 5. Hypertension. 6. Hypercholesterolemia. 7. Paroxysmal atrial fibrillation. 8. Gastroesophageal reflux disease. 9. Status post right upper lobectomy. 10. Status post bilateral cardiac surgery. DISCHARGE MEDICATIONS: Amiodarone 200 mg q.d., Lopressor 25 mg p.o. b.i.d., Coumadin 4 mg q.d., titrate goal INR 2.0-2.5, Aspirin 81 mg q.d., Lasix 20 mg q.d. x 10 days, Potassium Chloride 20 mEq q.d. x 10 days, Levoxyl 112 mcg q.d., Lipitor 20 mg q.d., Prilosec 40 mg q.d., Imdur 30 mg q.d., Colace 100 mg b.i.d., Percocet 5/325 [2-11] tab q.4 hours p.r.n. DISCHARGE STATUS: patient discharged home VNA. FO[Last Name (STitle) ]P: follow-up Dr. [Last Name (STitle) ] [4-13] weeks. Follow-up Dr. [First Name (STitle) 2031] [4-13] weeks. Follow-up Dr. [Last Name (Prefixes) ] four weeks. patient PT/INR drawn visiting nurses Friday, [12-24]. results called Dr.[Name (NI) 48166] office, manage patient's Coumadin dosing point forward. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2179-12-22] 18:27 T: [2179-12-22] 18:47 JOB#: [Job Number 48167]	[ "4019", "2724" ]
Admission Date: [2201-6-21] Discharge Date: [2201-7-3] Date Birth: [2171-2-21] Sex: Service: SURGERY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4691] Chief Complaint: Perforated diverticulitis Major Surgical Invasive Procedure: OSH procedure: [2201-6-20]: Exploratory laparotomy, sigmoid colectomy formation Hartmann's pouch colostomy [Hospital1 18] operations: [2201-6-26]: Exploratory laparotomy revision sigmoid colostomy [2201-6-28]: Abdominal washout, liver biopsy, abdominal closure History Present Illness: HPI: 30 yo male hx significant etoh abuse presenting OSH perforated sigmoid colon, s/p sigmoid colectomy, currently septic Neo. Intubated evening prior transfer. pt initially presented OSH one week abdominal pain, nausea vomiting associated diarrhea. CT scan ED demonstrated free air. Labs time pertinent ARF Cr. 2.3. Sodium 125, bicarb 22 AG 19 T.bili 3.8. Pt taken ex-lap found perforated viscous sigmoid area. Fibrinous exudate left side present c/w longstanding process. Hartmann pouch LLQ colostomy performed. pt started levaquin, flagyl zosyn. Postop pt persistent acidosis bicarb 15, lactate 4.8. started bicarb gtt. course OSH stay pt 9 liters positive. remains hypotensive neo. note pt drinks half-a-gallon day whiskey. last drink 8 days ago. Past Medical History: Alcohol abuse PSH: Hartmann's procedure Social History: History alcohol abuse Lives mother works [Hospital6 5016], patient admitted previosly Family History: Non-contributory Physical Exam: transfer [Hospital1 18]: 100 115 102/55 26 93% CMV 50% 450/13 5 Neuro: Awake responsive questions/follows commands Card: tachycardic, m/r/g/c Pulm: Intubated clear breath sounds bilaterally GI:+Bowel sounds. Midline incision c/d/i. dusky sunken appearing colostomy. Appropriately tender palpation Ext: peripheral edema palpable DP, radial pulses Pertinent Results: [6-21]: OSH CT abd/pelvis CT (OSH) free air sigmoid stranding/diverticulitis. Labs admission: [2201-6-21] 07:40PM WBC-7.4 RBC-2.62* HGB-9.5* HCT-29.2* MCV-112* MCH-36.1* MCHC-32.3 RDW-23.0* [2201-6-21] 07:40PM PLT COUNT-171 [2201-6-21] 07:40PM PT-16.4* PTT-31.7 INR(PT)-1.5* [2201-6-21] 07:40PM ALT(SGPT)-25 AST(SGOT)-58* ALK PHOS-52 TOT BILI-3.3* DIR BILI-2.9* INDIR BIL-0.4 [2201-6-21] 07:40PM GLUCOSE-141* UREA N-45* CREAT-1.8* SODIUM-138 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-20* ANION GAP-21* [2201-6-21] 07:40PM CALCIUM-6.5* PHOSPHATE-4.7* MAGNESIUM-2.2 [2201-6-21] 07:48PM freeCa-0.90* [2201-6-21] 07:48PM GLUCOSE-127* LACTATE-3.7* K+-3.4 [2201-6-21] 07:48PM TYPE-ART PO2-70* PCO2-37 PH-7.38 TOTAL CO2-23 BASE XS-- Brief Hospital Course: Mr. [Known lastname ] admitted trauma ICU [2201-6-21] management following Hartmann's procedure perforated diverticulitis septic shock. remained pressors weaned slightly overnight. received blood transfusion hematocrit 24.1 increased 25.9 weaned pressors. Copious secretions noted ET tube. Intraoperative cultures OSH obtained. peritoneal cultures polymicrobial. extubated remained hemodynamically stable transferred floor [2201-6-24]. time transfer floor pt NPO IV fluids NG tube suction. IV zosyn empiric coverage also foley catheter place urine output monitoring. [6-25] NG tube output remained low removed along foley catheter making good amounts urine. However, appearance stoma continued dusky necrotic WBC count increased 9.6 [6-24] 15.2 [6-26]. Therefore, taken back ostomy revision [2201-6-26]. Intraoperatively, received 3L crystalloid hypotension. abdomen left open due bowel edema brought trauma ICU intubated sedated. aggressively diuresed overnight abdomen closed [2201-6-28]. Also note, liver noted quite yellowed appearance suspicious acute fatty liver biopsy sent abdominal closure procedure (please see operative note details). Postoperatively, vent weaned continued diuresis. extubated [2201-6-29] transferred back floor hemodynamically stable. [6-30] noted gas small amout stool ostomy diet advanced tolerated. foley catheter placed upon return operating room removed voided without difficulty. vital signs routinely monitored remained afebrile hemodynamically. lung sounds noted crackles chest x-ray appreared wet diuresed lasix needed. white blood cell count began trending downward 18 27. hematocrit stabilized 27. encouraged mobilize bed ambulate tolerated throughout postoperative course remained SC heparin DVT prophylaxis. Ostomy nursing consulted provided appropriate treatment supplies patient care colostomy. HD #13, note mild erythema around lower aspect wound underwent removal staples lower aspect wound. Remained inferior staples removed POD #5 wound lightly packed wet dry dressing. patient instructed caring wound dressing changes. partipated dressing changes agreed continue them. VNA service also provide assistance. vital signs stable afebrile. preparing discharge home follow-up acute care clinic. Medications Admission: None Discharge Medications: 1. Ostomy supplies 1 piece Coloplast Sensura ( Dist # [Numeric Identifier 24338] [Doctor First Name ] # [Numeric Identifier 20839]) #3 boxes Refills:6 2. Ostomy Supplies [Last Name (un) ] wafer Dist # [Numeric Identifier 89560], manf # [Numeric Identifier 20840] #3 boxes Refills: 6 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. Disp:40 Tablet(s) Refills:0 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day needed constipation. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice day needed constipation. Discharge Disposition: Home Service Facility: [Hospital 16449] Homecare Hospice Discharge Diagnosis: Perforated diverticulitis Sepsis Acute Kidney Injury Ischemic sigmoid colostomy Open abdomen secondary diverticulitis sepsis Acute fatty liver Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: transferred [Hospital6 5016] undergoing emergent operation perforated diverticulitis. became septic postoperatively transferred [Hospital1 18] management. managed ICU condition improved transferred surgical floor. taken back operating stoma necrotic stoma revised. bowel swelling abdomen left open short period time. Two days later able closed operating room. also noted liver appeared abnormal biopsy taken last operation. results biopsy still pending time. infection improved colostomy functioning well. resumed regular diet continue so. discharged home following instructions: Please follow Acute Care Surgery Clinic appointment scheduled below. colostomy: received teaching ostomy nurses care stoma. Empty pouch becomes [2-10] full instructed. ACTIVITY: drive stopped taking pain medicine feel could respond emergency. may climb stairs. may go outside, avoid traveling long distances see [Month/Day (4) 5059] next visit. lift [11-23] lbs 6 weeks. (This weight briefcase bag groceries.) applies lifting children, may sit lap. may start light exercise feel comfortable. need stay bathtubs swimming pools time incision healing. Ask doctor resume tub baths swimming. Heavy exercise may started 6 weeks, use common sense go slowly first. [Month (only) ] FEEL: may feel weak "washed out" 6 weeks. might want nap often. Simple tasks may exhaust you. may sore throat tube throat surgery. might trouble concentrating difficulty sleeping. might feel somewhat depressed. could poor appetite while. Food may seem unappealing. feelings reactions normal go away short time. not, tell [Month (only) 5059]. INCISION: incision may slightly red around staples. normal. staples removed follow appointment clinic. may gently wash away dried material around incision. normal feel firm ridge along incision. go away. Avoid direct sun exposure incision area. use ointments incision unless told otherwise. may see small amount clear light red fluid staining dressing r clothes. staining severe, please call [Month (only) 5059]. may shower. noted above, ask doctor may resume tub baths swimming. Ove next 6-12 months, incision fade become less prominent. PAIN MANAGEMENT: normal feel discomfort/pain following abdominal surgery. pain often described "soreness". pain get better day day. find pain getting worse instead better, please contact [Name2 (NI) 5059]. receive prescription [Name2 (NI) 5059] pain medicine take mouth. important take medicine directied. take frequently prescribed. take medicine one time prescribed. pain medicine work better take pain gets severe. Talk [Name2 (NI) 5059] long need take prescription pain medicine. Please take pain medicine, including non-prescription pain medicine, unless [Name2 (NI) 5059] said okay. experiencing pain, okay skip dose pain medicine. Remember use "cough pillow" splinting cough deep breathing exercises. experience folloiwng, please contact [Name2 (NI) 5059]: - sharp pain severe pain lasts several hours - pain getting worse time - pain accompanied fever 101 - drastic change nature quality pain MEDICATIONS: Take medicines operation before, unless told differently. cases prescription antibiotics medication. questions medicine take take, please call [Name2 (NI) 5059]. DANGER SIGNS: Please call [Name2 (NI) 5059] develop: - worsening abdominal pain - sharp severe pain lasts several hours - temperature 101 degrees higher - severe diarrhea - vomiting - redness around incision spreading - increased swelling around incision - excessive bruising around incision - cloudy fluid coming wound - bright red blood foul smelling discharge coming wound - increase drainage wound Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] When: TUESDAY [2201-7-14] 2:30 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2201-7-8]	[ "5849" ]
Admission Date: [2143-4-29] Discharge Date: [2143-5-12] Date Birth: [2083-3-28] Sex: Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 348] Chief Complaint: abd pain, nausea/vomiting Major Surgical Invasive Procedure: Intubation Placement central venous catheter CVVHD Hemodialysis History Present Illness: 60 y/o w/alcohol abuse, HTN, presented [Hospital3 ] Saturday [4-27] c/o severe abd pain, n/v. started 2 days prior setting binge drinking whiskey. Pain epigastric radiating back. found lipase >3000. admitted medical service acute pancreatitis. kept NPO given IVF. also given Levaquin "lethargy" infiltrate CXR. next day, [4-28], bilirubin increased (0.8-2.6) continued severe abd pain, changed levaquin primaxin, trnasferred ICU. put lasix [Hospital1 ] due rales cardiomegaly, kept NS 100 cc/hr. CT scan po IV contrast showed acute pancreatitis intrahepatic ductal dilatation; multiple hypodense irregular lesions right lobe liver, thickened GB wall pericholecystic fluid, 5x4 cm hypodense collection RLQ adjacent psoas muscle. . [4-29], supposed go MRCP claustrophobic required ativan. this, felt better required ativan Radiology. [Name8 (MD) ] RN notes, heart rate "sporadic" 40s 160s. given ativan HR dropped 20s (bp 145/63 time). became diaphoretic, c/o chest pain, MRCP stopped. transferred stretcher turned [Doctor Last Name 352], "started seize" noted pulseless. [Name8 (MD) ] RN note, asystolic per d/c summary cardiology consult note, VT/VF. received "several" shocks CPR well one bolus dose amiodarone. intubated code. regained pulse unknown amt time. became hypotensive requiring dopamine. seen Renal due worsening renal failure (creatinine 0.8 admission 3.5 d/c) felt likely pre-renal failure volume depletion plus contrast CT. MRCP read showing small ascites, peripancreatic stranding, pericholecystic fluid, large gallstone. CBD appear dilated images quite limited; obvious intrahepatic biliary ductal dilatation pancreatic ductal dilatation. Complex T2 hyperintesnsity along right psoas muscle seen CT measuring 5.2 x3.7 cm, representing complex fluid collection. transferred management. Past Medical History: Alcohol abuse (reportedly binge drinks regularly) HTN Hypothyroidism ? pancreatitis Social History: Per OSH notes, "binge drinks time" recurrent bouts pancreatitis. Smokes tobacco, amt documented. Denied illicit drug use. Family History: unknown Physical Exam: admission: T: 99.4 BP: 87/49 P: 56 AC 500x14 FiO2 0.7 PEEP 5 O2 sat 94% CVP 13 Gen: intubated, sedated, paralyzed HEENT: icteric, ETT/OGT place, pupils constricted Lungs: CTA anteriorly, w/r/c CV: RRR, m/r/g Abd: distended, hypoactive present bowel sounds, tense difficult assess peritoneal signs paralyzed Ext: edema, feet cold, 1+ dp bilaterally Pertinent Results: Pre-admission labs note: [4-29] 9 pm: Na 136, K 6.0, Cl 108, Bicarb 18, BUN 56, Creat 3.7 Calcium 6.5, bili 10.0, AST 359, ALT 168, alk phos 161, CK 282, MB 6.2, MBI 2.1, Troponin 0.02 WBC 22 25% bands, Hct 42, Plt 157, INR 1.3 ABG 2:30 pm 6.88/83/68 ABG 6:30 pm 7.14/55/260 Urine cx <1000 colonies/ml Hepatitis serologies negative Lipase [4-29] 1541 Triglycerides 52 AFP 2.0 . EKG: [2143-4-30] Sinus rhythm. Left anterior fascicular block. Non-specific ST-T wave abnormalities. . Labs: [2143-4-30] 12:27AM BLOOD WBC-16.1* RBC-4.07* Hgb-12.9* Hct-38.7* MCV-95 MCH-31.6 MCHC-33.3 RDW-14.6 Plt Ct-153 [2143-4-30] 12:27AM BLOOD Plt Smr-NORMAL Plt Ct-153 [2143-4-30] 12:27AM BLOOD Neuts-69 Bands-16* Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2143-4-30] 12:27AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.2* [2143-4-30] 12:27AM BLOOD Glucose-339* UreaN-58* Creat-4.4* Na-139 K-5.8* Cl-108 HCO3-21* AnGap-16 [2143-4-30] 12:27AM BLOOD ALT-134* AST-313* LD(LDH)-1755* CK(CPK)-559* AlkPhos-142* Amylase-[2143]* TotBili-7.6* [2143-4-30] 12:27AM BLOOD Lipase-1032* [2143-4-30] 12:27AM BLOOD CK-MB-9 cTropnT-0.15, 0.14, 0.13 . Micro: See OMR . Imaging: [2143-4-30]: Abd u/s - 1. Minimal ascites right upper right lower quadrants. 2. Gallstone neck gallbladder edema gallbladder wall. could reflect acute cholecystitis also could manifestation changes due patient's known acute pancreatitis. 3. intrahepatic extrahepatic biliary dilatation. 4. Patent portal vein. . [2143-5-3]: Head CT - Diffuse hypodensity loss [Doctor Last Name 352]-white differentiation suggesting global hypoxia infarction. However, similar appearance could caused severe acute hepatic renal failure. Subacute left parietal infarction without hemorrhage. Possible small right parietal subacute infarction. Brief Hospital Course: brief, patient 60 year old man history alcohol abuse, admitted OSH severe acute pancreatitis/pseudocyst, complicated cardiac arrest, ARDS transferred management. patient treated [Hospital1 18] ICU approximately two weeks without recovery neurologic function. time, treated ARDS, severe pancreatitis, acute renal failure (with CVVHD HD), anemia, altered mental status. patient remained unresponsive weaning sedation, patient's family agreed made comfort measures given severely depressed mental status due anoxic brain injury. conclusion established aid Neurology consultants. time, patient transferred ICJ general medicine floor. passed away [5-12], [2142]. Medications Admission: 1. Amlodipine 10 mg daily 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Lisinopril 40 mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Anoxic brain injury secondary cardiac arrest Necrotizing pancreatitis Alcohol abuse Renal failure Adult respiratory distress syndrome Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2143-5-13*]	[ "4019", "2449", "2859" ]
Admission Date: [2166-4-9] Discharge Date: [2166-4-18] Date Birth: [2108-8-25] Sex: Service: Fernard Intensive Care Unit HISTORY PRESENT ILLNESS: Mr. [Known lastname 405] 57-year-old male presented [Hospital 1474] Hospital [2166-4-8] hematemesis. patient treated transfusions octreotide. Esophagogastroduodenoscopy done unsuccessful therapeutic treatment upper gastrointestinal bleed. patient transferred [Hospital1 188] [2166-4-9], [Initials (NamePattern4) ] [Last Name (NamePattern4) ] transjugular intrahepatic portosystemic shunt procedure. Indications included gastric variceal bleed refractory endoscopic treatment. patient electively intubated prior transfer. [2166-4-10], patient transjugular intrahepatic portosystemic shunt procedure complicated innominate vein perforation right internal mammary artery bleed hemothorax. patient taken operating room sternotomy repair vascular lesions. patient stabilized, chest tube placed. patient required 12 units packed red blood cells, 4 units platelets, 4 units fresh frozen plasma. initial period stability, patient became increasingly hypotensive [2166-4-12] [2166-4-14] requiring pressor support. Swan-Ganz catheter placed systemic vascular resistance decreased, cardiac output index increased. patient transferred Fernard Intensive Care Unit care given picture sepsis. note, packed red blood cell requirement 3 units per day three days stopped bleeding clinically. nasogastric tube output. patient still [Last Name (un) ] tube place. patient paralyzed due difficulty ventilation postoperatively. operating room [4-10], patient episode hypotension one three minutes. PAST MEDICAL HISTORY: 1. Cirrhosis. 2. Status post esophageal variceal bleed. 3. Status post transjugular intrahepatic portosystemic shunt unsuccessful. 4. Status post innominate vein right internal mammary artery laceration resultant hemothorax. 5. Status post sternotomy described. ALLERGIES: known drug allergies. MEDICATIONS TRANSFER: Medications transfer Surgical Intensive Care Unit octreotide 50 mcg q.d., insulin drip, Dilaudid drip, Ativan drip, oxacillin 2 g q.6h., levofloxacin 500 mg intravenously q.d., Flagyl 500 mg intravenously t.i.d., Protonix 40 mg intravenously b.i.d., Cisatracurium 80 mcg/kg per hour, Neo-Synephrine drip. PHYSICAL EXAMINATION PRESENTATION: Blood pressure 110/50, pulse 80, temperature 37. patient ventilatory support AC 550 X 12 FIO2 60%, positive end-expiratory pressure 20. Swan-Ganz catheter readings follows: Central venous pressure 22, pulmonary artery pressure 44/19, cardiac output 7.8, cardiac index 3.95, systemic vascular resistance 522. Ins-and-outs 2700 1800 out; 1300 urine. general, patient intubated sedated. Pupils small reactive. Neck revealed left internal jugular place; site looks clean. oropharynx clear. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] place; purulent green discharge noted. Chest revealed fair breath sounds bilaterally, positive rhonchi throughout. Cardiovascular regular rate rhythm. murmurs, rubs gallops. Abdomen soft, decreased bowel sounds. Extremities warm fair pulses distally. Skin rash. Right radial femoral lines purulent discharge noted either line. PERTINENT LABORATORY DATA PRESENTATION: White blood cell count 13.4 (decreased 19.6), hematocrit 33.4, platelets 146. PT 15.4, PTT 42.2, INR 1.7. Chemistry-7 significant creatinine 1.5 (increased baseline 1). Albumin 2.7, phosphate 4.5, magnesium 2.1. ALT 19, AST 32, alkaline phosphatase 108, total bilirubin 13.1 (increased admission 6). Urine sodium 19 [2166-4-11]. Arterial blood gas revealed 7.4, PCO2 34, PO2 135, unknown FIO2, lactate 3. Blood cultures revealed growth date far. Sputum positive methicillin-sensitive Staphylococcus aureus. RADIOLOGY/IMAGING: chest x-ray revealed bilateral infiltrates suggestive congestive heart failure. HOSPITAL COURSE: summary, 57-year-old male recent gastric variceal bleed, status post unsuccessful transjugular intrahepatic portosystemic shunt complicated hemothorax innominate vein injury requiring thoracotomy, hypotensive pressors requiring increased FIO2 positive end-expiratory pressure maintain oxygenation. Swan-Ganz catheter numbers physical complete blood count increased white blood cell count left shift suggestive sepsis. patient paralyzed due difficulty ventilation postoperatively. patient seemed longer bleeding varices. 1. PULMONARY: Given decreased blood pressure tried decrease positive end-expiratory pressure tolerated tried wean paralytics. patient also given fluid maintain blood pressure. Diuresis option given decreased blood pressure. Swan-Ganz catheter placed perioperatively subsequently discontinued. 2. CARDIOVASCULAR: patient requiring Neo-Synephrine increase blood pressure. tried wean Neo-Synephrine add vasopressin; however, unsuccessful. 3. GASTROINTESTINAL: patient stable hematocrit longer transfusion requirement. patient continued Protonix, [Last Name (un) ] tube continued left in. patient hyperbilirubinemia; likely thought secondary shocked liver given episode hypotension. 4. RENAL: Creatinine increased 1.5 continued increase hospitalization. thought likely secondary hepatorenal syndrome. patient continued maintain good urine output. [4-26], patient started octreotide midodrine given possibility hepatorenal syndrome; however, creatinine continued increase. 5. ENDOCRINE: patient maintained insulin drip later changed subcutaneous. 6. HEMATOLOGY: patient's hematocrit remained stable. coagulopathy likely secondary liver disease. 7. INFECTIOUS DISEASE: Oxacillin changed vancomycin given patient continued febrile. also thought patient may sinusitis secondary [Last Name (un) ] tube; however, Gastroenterology felt [Last Name (un) ] tube kept given recent episode upper gastrointestinal bleed. patient continued vancomycin, levofloxacin, Flagyl general sepsis cover sinusitis, mediastinitis, Staphylococcus aureus sputum. 8. FLUIDS/ELECTROLYTES/NUTRITION: patient initiated total parenteral nutrition. patient significantly improve, given worsening renal function, thought patient's prognosis poor. family meeting, patient made resuscitate. [4-18], given poor prognosis, family decided make patient comfort measures only. 11:58, patient expired. CONDITION DISCHARGE: Expired. DISCHARGE DIAGNOSES: 1. Gastric variceal bleed secondary cirrhosis. 2. Cirrhosis; likely secondary ethanol use. 3. Hemothorax secondary transjugular intrahepatic portosystemic shunt procedure; status post sternotomy stabilization perforations. 4. Sepsis. 5. Acute respiratory distress syndrome (ARDS). [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2166-8-29] 11:36 T: [2166-9-4] 16:33 JOB#: [Job Number 40542]	[ "5849" ]
Admission Date: [2139-2-17] Discharge Date: [2139-2-24] Date Birth: [2072-4-24] Sex: Service: CT Surgery HISTORY PRESENT ILLNESS: patient 66 year old male presented exertional angina. patient noted two months exertional angina band-like chest pain radiating left arm, relieved sublingual nitroglycerin. day admission, patient stress test developed 1.[Street Address(2) 1755] elevations inferiorly [Street Address(2) 2051] depressions V4 V6. Imaging showed severe reversible perfusion defect inferior lateral walls. Cardiac catheterization performed, demonstrating 60% 70% stenosis left anterior descending artery, 90% left circumflex, 90% right coronary artery left ventricular ejection fraction approximately 50%. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Hypercholesterolemia. MEDICATIONS ADMISSION: Lisinopril 40 mg p.o.q.d., lovastatin 20 mg p.o.q.d., hydrochlorothiazide 25 mg p.o.q.d., amlodipine 10 mg p.o.q.d., metformin 500 mg p.o.q.d., NPH insulin 36 units q.a.m. 32 units q.p.m., terazosin 1 mg p.o.q.d., Zyrtec 10 mg p.o.q.d., Ecotrin p.o.q.d. ALLERGIES: patient known drug allergies. PHYSICAL EXAMINATION: physical examination, patient heart rate 70s, blood pressure 134/71 oxygen saturation 98% two liters. General: Patient acute distress. Neck: jugular venous distention. Cardiovascular: Regular rate rhythm, I/VI systolic murmur. Lungs: Clear auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: edema. HOSPITAL COURSE: patient admitted hospital decided would taken Operating Room [2139-2-19]. Coronary artery bypass grafting performed left internal mammary artery left anterior descending artery saphenous vein grafts obtuse marginal, posterior descending artery diagonal three artery. pericardium left open arterial line placed. Two atrial wires placed. Two mediastinal one left pleural tube placed. Crossclamp time 61 minutes. Postoperatively, patient transferred Intensive Care Unit, rapidly extubated. postoperative day number one, Neo-Synephrine drip appropriately weaned. patient A-V paced. postoperative day number one chest tubes also removed. postoperative day number two, patient transferred floor. Foley catheter removed postoperative day number two. atrially paced entire day posterior day two. postoperative day number three, wires capped patient heart rate 70 sinus rhythm. Wires removed postoperative day number five. patient able ambulate level V, tolerating oral diet, pain controlled oral medications. CONDITION DISCHARGE: Stable. DISCHARGE MEDICATIONS: Lasix 20 mg p.o.b.i.d. times seven days. Potassium chloride 20 mEq p.o.q.d. times seven days. Lopressor 12.5 mg p.o.q.d. Percocet one two tablets p.o.q.4-6h.p.r.n. Lovastatin 20 mg p.o.q.d. Amlodipine 10 mg p.o.q.d. Glucophage 500 mg p.o.q.d. NPH insulin 36 units q.a.m. 32 units q.p.m. Terazosin 1 mg p.o.q.d. Ecotrin 325 mg p.o.q.d. Colace 100 mg p.o.b.i.d. DI[Last Name (STitle) 408]E FOLLOW-UP: patient follow primary care physician cardiologist three weeks Dr. [Last Name (Prefixes) ] four weeks. DISCHARGE DIAGNOSIS: Status post coronary artery bypass grafting times four. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 1308] MEDQUIST36 D: [2139-2-24] 11:28 T: [2139-2-24] 11:33 JOB#: [Job Number 29720]	[ "4019", "2720" ]
Admission Date: [2153-1-5] Discharge Date: [2153-1-11] Date Birth: [2067-1-25] Sex: Service: MEDICINE Allergies: Codeine / Iodine Attending:[First Name3 (LF) 2782] Chief Complaint: malaise Major Surgical Invasive Procedure: Percutaneous Chol. History Present Illness: 85 yo male w/ h/o Afib, systolic CHF, recent cholecystitis treated medically p/w fatigue, poor po intake, malaise. Upon questioning admits mild ruq pain chills fevers. lost ten lbs last week due poor po intake. son brought [Name (NI) ] evaluation appointment cardiologist's office. . hospitalized [2152-12-10] OSH rx cholecytitis afterwhich developed lower extremity edema dyspnea exertion. started lasix one week ago improved since then. says gets extremely short breath 20 steps. chest pain. . several mechanical falls lately reason, anticoagulated. ED, initial VS were: 97.8 48 95/76 18 90%. given 1.5L ivf. treated azithromycin 500mg iv once, ceftriaxone 1g iv once, unasyn 3g iv once. Lactate decreased 4.6 2.2 fluids. Troponin stable .03. Surgical consultation recommends percutaneous cholecystostomy tubes. CT head . Upon transfer micu, 98.0, Pulse: 94, RR: 16, BP: 129/72, O2Sat: 97%, O2. arrival MICU, acute complaints. . Review systems: (+) Per HPI (-) Denie night sweats, recent wt gain. Denies headache, sinus tenderness, rhinorrhea congestion. Denies wheezing. Denies chest pain, chest pressure, palpitations, weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, changes bowel habits. Denies dysuria, frequency, urgency. Denies arthralgias myalgias. Denies rashes skin changes. Past Medical History: S/P BILATERAL TKR S/P ILIAL FRACTURE ATRIAL FIBRILLATION AWB DONATION- DEFFERRAL B12 DEFICIENCY ANEMIA BLADDER CANCER CERVICAL SPONDYLOSIS CHRONIC RENAL FAILURE GASTROESOPHAGEAL REFLUX HERNIATED DISC HYPERCHOLESTEROLEMIA HYPERTENSION HYPOTHYROIDISM MGUS MITRAL VALVE PROLAPSE PROCTITIS PROSTATE CANCER R SHOULDER DJD TRANSIENT ISCHEMIC ATTACK [2141] LVEF 25% Social History: lives alone daily help; smoking etoh Family History: Mother died alzheimers dementia Father died prostate cancer Physical Exam: General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated, LAD CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Admission Labs [2153-1-5] 09:45PM GLUCOSE-136 UREA N-41* CREAT-1.8* SODIUM-141 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [2153-1-5] 09:45PM CALCIUM-8.1* PHOSPHATE-4.3 MAGNESIUM-2.0 [2153-1-5] 12:03PM URINE HOURS-RANDOM UREA N-932 CREAT-99 SODIUM-50 POTASSIUM-68 CHLORIDE-41 [2153-1-5] 12:03PM URINE OSMOLAL-595 [2153-1-5] 12:03PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2153-1-5] 04:49AM GLUCOSE-136* UREA N-45* CREAT-2.1* SODIUM-139 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17 [2153-1-5] 04:49AM ALT(SGPT)-55* AST(SGOT)-55* LD(LDH)-255* ALK PHOS-128 TOT BILI-0.6 [2153-1-5] 04:49AM CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-2.0 IRON-38* [2153-1-5] 04:49AM calTIBC-179* VIT B12-740 FOLATE-GREATER TH FERRITIN-246 TRF-138* [2153-1-5] 04:49AM WBC-8.6 RBC-3.08* HGB-9.9* HCT-30.7* MCV-100* MCH-32.2* MCHC-32.4 RDW-17.9* [2153-1-5] 04:49AM PLT COUNT-239 [2153-1-5] 04:49AM PT-13.4* PTT-20.7* INR(PT)-1.2* [2153-1-5] 01:04AM LACTATE-2.2* [2153-1-5] 12:55AM cTropnT-0.03* [2153-1-4] 08:25PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2153-1-4] 08:25PM URINE RBC-1 WBC-10* BACTERIA-MANY YEAST-NONE EPI-0 [2153-1-4] 08:25PM URINE MUCOUS-RARE [2153-1-4] 06:25PM LACTATE-4.6* K+-4.8 [2153-1-4] 06:25PM HGB-11.3* calcHCT-34 [2153-1-4] 06:12PM PT-14.7* PTT-24.4* INR(PT)-1.4* [2153-1-4] 06:12PM PLT COUNT-267# [2153-1-4] 06:12PM cTropnT-0.03* [2153-1-4] 06:12PM LIPASE-33 Brief Hospital Course: BRIEF HOSPITAL COURSE: 85 year old gentleman history atrial fibrillation, systolic heart failure recent medically treated cholecystitis presented recurrent cholecystitis treated percutaneous drainage antibiotics. hospital course complicated delirium mild pulmonary edema. . ACTIVE ISSUES: ACUTE CHOLECYSTITIS: Mr. [Known lastname 79] presented right upper quadrant pain nausea fatigue. Labs significant normal LFTs. RUQ ultrasound demonstrate dacute cholecystitis. Suurgery consulted recommended percutaneous drainage gallbladder carried IR. Initial pus drained gallbladder transioned bilious drainage Day # 2 admission. covered Vancomycin Zosyn initially. Culture data biliary drain grew ecoli sensitive ciprofloxacin. Antibiotic therapy changed ciprofloxacin metronidazole include anaerobic coverage total 14 days. biliary drain kept place plan discontinuation general surgery [5-25] weeks. afebrile duration hospital course. . CONGESTIVE HEART FAILURE: admission noted dyspneic. initial chest xray concerning right lower lobe pneumonia could ruled setting pulmonary edema. initially vancomycin zosyn admission intensive care unit. diuresis initially held secondary concern acute kidney injury pulmonary edema accumulated initial hospital days. given IV lasix 20mg twice restarted home dose lasix 20mg daily. dose uptitrated 40mg daily appeared better control volume status improved breathing. echo demonstrated symmetric left ventricular hypertrophy cavity dilation global systolic dysfunction suggestive non-ischemic pattern EF 25%. low dose ace-inhibitor (lisinopril 5mg) started continued aspirin beta blocker. reported cough afebrile duration hospitalization. repeat chest xray diuresis revealed evidence pneumonia. nighttime oxygen saturations noted stably low 90s. . URINARY TRACT INFECTION: urine sample admission concerning infection culture grew ecoli sensitive ciprofloxacin. repeat UA prior discharge clear infection. . ATRIAL FIBRILLATION: Mr. [Known lastname 79] rate controlled metoprolol anticoagulated aspirin given fall risk. noted heart rates 110s frequent episodes non sustained ventricular tachycardia, therfore metoprolol incrased 50mg three times day improvement frequency NSVT heart rates 60-70s day. Cardiology consulted agreed management changes. question whether domperidone past. taken medication list. . DELIRIUM: Mr. [Known lastname 79] noted progressive delirium throughout hospitalization improving prior discharge. pharmacologic agents required management. attentive family bedside times. Repeat infectious work-up including UA, chest xray cdiff toxin negative infection. electrolytes stable. Etiology attributed age, dementia hospitalization including ICU stay. . SPEECH SWALLOW: delirius, Mr. [Known lastname 79] noted small aspiration events eating drinking. speech swallow evaluation recommended nectar thickened liquids suggested re-evaluation delirium clears. . INACTIVE ISSUES CHRONIC KIDNEY DISEASE: renal function ranged 1.8 2.0 throughout hospitalization baseline. . HYPERTENSION: Well controlled. Furosemide increased 40mg PO. Amlodipine discontined favor lisinopril 5mg. Hydralazine held discharge given normotensive. discuss restarting medication primary care physician discharge. . HYPOTHYROID: continued levothyroxine. . VITAMIN D: continued vitamin D. . DYSLIPIDEMIA: continued crestor 20mg daily. . DEPRESSION: continued wellbutrin 300mg daily. . BENIGN PROSTATIC HYPERTROPHY: continued flomax. . PAIN: Secondary frequent falls. continued tylenol gabapentin. . INSOMNIA: Lunesta held admission reconsidered discharge. . GERD: continued ranitidine nexium. . TRANSITIONAL ISSUES: - Continue ciprofloxacin metronidazole 8 additional days - Primary care follow-up, Electrolytes checked within 1 week started lasix lisinopril. - Full Code Medications Admission: tylenol #3 daily prn furosemide 20mg daily amlodipine 5mg daily bupropion 300mg daily calcitriol .25mcg domperidone 5mg daily gabapentin 900mg daily esmeprasole 40mg daily eszopiclone (lunesta) 2mg hs gabapentin 800mg daily hydralazine 25mg [Hospital1 ] levothyroxine 112 mcg daily metoprolol succinate 50mg [Hospital1 ] ranitidine 150mg daily rosuvastatin 20mg daily tamsulosin .4mg daily asa 325 vitamin b12 1000mcg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed pain. 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO day. 4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO day. 5. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO bedtime needed insomnia. 6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin 2,000 unit Capsule Sig: One (1) Capsule PO day. 11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO day. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 8 days: day 1 = [1-5] (total course 14 days). 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) 8 days: day 1 = [1-5] (total 14 days). 14. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO day. 15. gabapentin 800 mg Tablet Sig: One (1) Tablet PO day. 16. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO day. 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO day. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 1495] [Hospital 122] Rehabilitation Center Discharge Diagnosis: Acute cholecystitis Urinary tract infection Atrial fibrillation Decompensated systolic heart failure Hypertension Chronic kidney disease Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: pleasure taking care you. came feeling fatigue fever. reason inflammation galbladder urinary tact infection. tube placed gallblader bile drain. gave antibiotics recovered. . tube stay gallbladder. Wou see surgeon [1-26] give instructions. . done following changes medications: CONTINUE ciprofloxacin 500 mg tbl. twice day 8 days CONTINUE metronidazole 500 mg tbl. three times day 8 days CHANGE furosemide 20 mg po daily furosemide 40 mg daily DISCONTINUE dronedorol DISCONTINUE amlodipine 5 mg daily START lisinopril 5 mg daily DISCONTINUE hydralazine 25 mg twice day DISCONTINUE ranitidine 150 mg daily Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: FRIDAY [2153-1-26] 10:15 With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2153-2-7] 11:30 With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage . Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2153-3-28] 11:30 With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "5990", "5849", "4280", "2449", "2724", "2720" ]
Admission Date: [2166-4-30] Discharge Date: [2166-5-9] Date Birth: [2100-7-6] Sex: F Service: MEDICINE Allergies: Amoxicillin / Bactrim / Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 613] Chief Complaint: s/p fall Major Surgical Invasive Procedure: None History Present Illness: 65 y.o. female PMHx COPD, esophageal stricture s/p dilatation [Month (only) 404] presents chief complaint falls. Patient reports long history falls, 1 fall day past 3 consecutive days. reports dizziness occasionally prior falls, otherwise denies prodrome chest pain, SOB, palpitations. reports hitting head falls, denies LOC. also recently fell right chest subsequent pain. attributes falls decreased vision (has history cataracts s/p two surgeries right, many years ago) also supposed ambulate walker, always comply. also wears 2 liters oxygen baseline noted occasionally trips oyxgen tubing trying ambulate. thus primarily comes complaint falls, noted cough productive yellow/brown sputum past 2 months subjective fevers (sweats) evaluated. reports grandchildren well gentleman building potential sick contacts, otherwise denies recent travel exposures. report getting flu shot last year receiving pneumovax 2 years ago. . ED, patient noted tachycardic 120s hypoxic 89% RA. improved 96% NRB failed attempt nasal cannula. Patient also noted lactate 3.3 leukocytosis 22.8 bandemia 9%. CXR showed right middle lower lobe infiltrates, concerning PNA given hypoxia, lactic acidosis leukocytosis, patient started Levofloxacin Ceftriaxone. Otherwise, patient noted acute renal failure 0.6 1.3 given 1 L NS. Additionally, potassium 2.4 repleted. EKG performed unremarkable, troponin x 1 elevated 0.05 setting ARF ASA given. Patient asymptomatic otherwise. Lastly, given history recent falls, CT neck head performed without evidence fracture bleed. Patient subsequently admitted ICU management probable pneumonia significant hypoxia bandemia. . Upon arrival ICU, patient NRB, speaking full sentences, acute distress. complained right sided chest pain due fall also endorsed dysuria hematuria. Otherwise, complaints. Past Medical History: #Esophageal stricture s/p dilatation [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] #Peptic ulcer disease s/p subtotal gastrectomy repair hiatal hernia fundoplication [2163-8-19] Dr. [Last Name (STitle) ] nonhealing ulcer #COPD (no PFTs OMR) #GERD #Depression #PTSD #Anemia #Hyperlipidemia #C-section x 2 ('[27], '[28]) Social History: Lives alone [Hospital3 ] [Hospital1 3494] SSI disability. Still continues smoke unquantified amount. denies alcohol illicit drugs. 3 children, estranged them. victim domestic disputes ex-husband, currently lives alone feels safe. Family History: Asthma (children), brother depression PTSD Physical Exam: Vitals: T: 99.0, BP: 141/87, P: 110 R: 24 O2: 94% 4L NC. General: Awake, alert, NAD, speaking full sentences, accessory muscle use. HEENT: NC/AT; pale conjunctiva, PERRLA, EOMI; OP clear, nonerythematous Neck: Supple, JVD Lungs: Decreased BS bilaterally, wheezes, ronchi, crackles CV: RR, normal S1 + S2, [1-24] SM 2RICs radiating, murmurs, rubs, gallops Abdomen: Soft, tender palpation RLQ, rebound guarding, + BS, old midline surgical incision Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema . Neuro: Alert, oriented x 2, attention impaired. Pt. unable cooperate full neurlogical exam. Proprioception appears impaired LLE, upgoing toes b/l. DTRs 3+ patella b/l. Impaired FTN [Doctor First Name ]. Pertinent Results: Labs admission discharge: . [2166-4-30] 05:10PM BLOOD WBC-23.8# RBC-3.35 Hgb-7.9* Hct-25.8* MCV-77# MCH-23.5# MCHC-30.5* RDW-16.9* Plt Ct-548* [2166-4-30] 07:35PM BLOOD Neuts-72* Bands-19* Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2166-5-7] 07:05AM BLOOD WBC-11.6* RBC-3.00* Hgb-7.7* Hct-23.3* MCV-78* MCH-25.6* MCHC-32.9 RDW-18.3* Plt Ct-431 . [2166-4-30] 05:10PM BLOOD PT-15.8* PTT-33.1 INR(PT)-1.4* . [2166-5-5] 07:50AM BLOOD Ret Aut-0.3* . [2166-4-30] 05:10PM BLOOD Glucose-181* UreaN-31* Creat-1.3* Na-136 K-2.4* Cl-95* HCO3-24 AnGap-19 [2166-5-7] 07:05AM BLOOD Glucose-122* UreaN-3* Creat-0.5 Na-141 K-3.1* Cl-100 HCO3-33* AnGap-11 . [2166-4-30] 05:10PM BLOOD ALT-11 AST-25 CK(CPK)-794* AlkPhos-122* TotBili-0.5 . [2166-4-30] 05:10PM BLOOD cTropnT-0.05* [2166-5-1] 12:00AM BLOOD CK-MB-5 cTropnT-0.05* [2166-5-1] 06:15AM BLOOD CK-MB-6 cTropnT-0.03* . [2166-4-30] 05:10PM BLOOD Calcium-8.7 Phos-2.3# Mg-2.1 Iron-7 [2166-4-30] 05:10PM BLOOD calTIBC-256* Ferritn-160* TRF-197* [2166-5-1] 06:15AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.6* Mg-2.7* . [2166-4-30] 05:27PM BLOOD Lactate-3.3* [2166-5-1] 01:12AM BLOOD Lactate-1.0 [2166-5-3] 04:48AM BLOOD TSH-0.33 . [2166-4-30] 05:55PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2166-4-30] 05:55PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2166-4-30] 05:55PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 [2166-4-30] 10:49PM URINE Eos-NEGATIVE [2166-4-30] 10:49PM URINE Hours-RANDOM Na-LESS . [2166-5-6] 04:01AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2166-5-6] 04:01AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2166-5-6] 04:01AM URINE RBC-45* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 . Microbiology: . [2166-5-7] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING INPATIENT [2166-5-7] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-PENDING INPATIENT [2166-5-6] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-FINAL INPATIENT [2166-5-6] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-6] URINE URINE CULTURE-FINAL INPATIENT [2166-5-6] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-5] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-5] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-4] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . [2166-5-2] URINE Legionella Urinary Antigen - negative . [2166-5-1] BLOOD CULTURE Blood Culture, Routine-no growth [2166-5-1] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-mixed flora . [2166-4-30] URINE URINE CULTURE-mixed flora [2166-4-30] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2166-4-30] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2166-4-30] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] . Blood Culture, Routine (Final [2166-5-6]): STREPTOCOCCUS PNEUMONIAE. MEROPENEM = 0.016 MCG/ML = SENSITIVE E-TEST. Penicillin SENSITIVE 0.032 MCG/ML Sensitivity testing performed Etest. CEFTRIAXONE SENSITIVE 0.023 MCG/ML Sensitivity testing performed Etest. Note: treatment meningitis, penicillin G MIC breakpoints <=0.06 ug/ml (S) >=0.12 ug/ml (R). Note: treatment meningitis, ceftriaxone MIC breakpoints <=0.5 ug/ml (S), 1.0 ug/ml (I), >=2.0 ug/ml (R). treatment oral penicillin, MIC break points <=0.06 ug/ml (S), 0.12-1.0 (I) >=2 ug/ml (R). sensitivity testing performed [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE \| ERYTHROMYCIN---------- PENICILLIN G---------- TETRACYCLINE---------- TRIMETHOPRIM/SULFA---- VANCOMYCIN------------ . Imaging/studies: . CXR admission: . FINDINGS: Portable upright AP chest radiograph obtained. patchy consolidation right mid lower lung, concerning right middle lower lobe pneumonia. left lung appears essentially clear. Cardiomediastinal silhouette appears grossly unremarkable. pneumothorax. Bony structures appear intact. . IMPRESSION: Findings concerning right middle lower lobe pneumonia. . ECG admission: Sinus tachycardia, rate 118. Low voltage standard leads. Left atrial abnormality. Compared previous tracing [2165-8-28] sinus tachycardia new borderline first degree A-V block. . CT head admission: . NON-CONTRAST HEAD CT: hemorrhage, edema, mass effect, acute large vascular territory infarction. extensive periventricular white matter hypodensity, consistent sequelae small vessel ischemic disease. mild prominence sulci ventricles, likely secondary global parenchymal atrophy. shift normally midline structures. basilar cisterns preserved. Osseous structures surrounding soft tissues, including globes orbits, unremarkable. left lens appears prosthetic. visualized paranasal sinuses mastoid air cells normally pneumatized clear. IMPRESSION: 1. Global parenchymal atrophy sequelae small vessel ischemic disease. 2. hemorrhage, edema, mass effect, acute large vascular territory infarction. . CT neck admission: . IMPRESSION: 1. fracture malalignment. 2. Mild multifocal cervical spondylosis evidence canal stenosis. 3. Biapical pleural scarring. . CT chest [5-1]: . IMPRESSION: 1. Findings consistent multifocal pneumonia without evidence cavitation. Partial right middle left lower lobe atelectasis small bilateral pleural effusions. 2. Boarderline enlarged mediastinal lymph nodes, likely reactive nature. 3. 2.6-cm benign-appearing left adrenal lesion. . CXR [5-2] - . Since yesterday, right mid lower lung opacity increased. Left upper mid lung opacity also increased, worrisome rapidly progressing multifocal pneumonia, could Legionella. Small left pleural effusion also increased. Tiny right pleural effusion unchanged. cardiomediastinal silhouette hilar contours otherwise normal . ECHO [2166-5-5]: . left atrium right atrium normal cavity size. estimated right atrial pressure 0-5 mmHg. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%). estimated cardiac index normal (>=2.5L/min/m2). Right ventricular chamber size free wall motion normal. diameters aorta sinus arch levels normal. aortic valve leaflets (?#) appear structurally normal good leaflet excursion. masses vegetations seen aortic valve, cannot fully excluded due suboptimal image quality. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. pulmonary artery systolic pressure could determined. pericardial effusion. IMPRESSION: Suboptimal image quality. valvular pathology pathologic flow identified. . CXR [5-5]: IMPRESSION: Right upper right middle lobe pneumonia, significantly changed. Small right pleural effusion. . CT chest [2166-5-6] . IMPRESSION: 1. Consolidation left lung almost completely resolved. 2. Consolidations right middle lobe right upper lobe new areas cavitation present. 3. Unchanged left adrenal lesion. 4. Persistent slight decreased small effusions, greater right side. Brief Hospital Course: 65 y.o. female PMHx significant COPD esophageal stricture, s/p dilatation [Month (only) 404] presents multifocal Streptococcal PNA, sepsis. . Brief ICU course: . diagnosed w/ PNA via CT w/ S. pneumococcal bacteremia ([2-19] BCx [4-30]). started IV CFTX Levaquine. BCx negative since starting CFTx Levofloxacin, persistent WBC count low grade fevers. treated w/ ABx above, last fever noted [5-1] 101F prior transfer floor, low grade 100 fevers since admission. oxygen requirement improved 4L NC RR decreased 18-22. Pt. also noted microcytic anemia unclear etiology, nadir HCT 18, transfused 2 U prbcs since HD stable w/ HCT mid 20s. Finally, patient tachycardic 100s - 110s, sinus rhythm. felt due sepsis. transferred medical floor management. . course complicated worsening WBC fever medical floor RML consolidation developing cavitations, multiple loose stools. Please see detailed discussion problems. . # PNA S.Pneumo Sepsis. Infiltrates felt due CAP resultant bacteremia (strep pneumo). Pt. persistent leukocytosis. aspiration noted Video swallow, however noted penetration thin liquids. continued CFTX floor. However, [5-6], developed Fever, increasing O2 requirement. pancultured CT repeated showing improved L consolidation, slight improvement right new air loculations. Due concern empyema (staph strep), ABx regimen broadened Vancomycin Zosyn treatment HAP Aspiration PNA. Patient remained HD stable. Due wheezing exam, started standing ipratropium albuterol nebulizers. treatment, WBC continued improve, O2 requirement resolved. episode fever [5-6] 101.3F. CT chest obtained showed improved infiltrate L R, newe air loculation. broadened Vanco/Zosyn one day defervesced prior ABx administered. Pulmonary team consulted regardging bronchoscopy, decided face clinical improvement likelyhood cavitation [1-20] Strep Pneumo and/or anaerobes (too short course Staph developed cavitation < 24hrs VAP). switched Cefpodoxime PO Flagyl PO 2 weeks (day 1 = [5-8], pt already received 7 days either CFTX/Levofloxacin Vanc/Zosyn) total course 3 weeks. require follow CXR end 2 weeks (last day [2166-5-22]). PCP follow arranged [5-19]. Please fax summary rehab course notes PCPs office prior discharge. require weaning nebulizers restarting home advair starting tiotropium COPD. . # Leukocytosis: Likely reactive pulmonary infection vs. C.diff. patient loose stools ABx > 5d prior onset diarrhea. Given high grade bacteremia new murmur, TTE obtained show vegetations. first C.Diff negative tx empiricaly PO Vanco given persistently loose stools Age > 65. UA/UCx negative. C.Diff retunred negative x3 PO vanco discontinued [5-8] 2 days tx. started Flagyl above. remained afebrile since [5-5] WBC 11 day discharge. persistent [Last Name (un) 940] stools, lower frequency, 5 -> 3/day. . # Anemia, microcytic. Hct baseline, 29-30. Currently HCT 23-25, admission s/p 2U PRBCs. Pt. hx iron deficiency anemia, confirmed labs [2162]. Previously iron stopped unclear reasons. colonoscopy system, patient history UGI bleed, last EGD unremarkable. Guaiac negative ED. signs hemolysis. Anemia felt multifactorial (ACD, Fe defficiency). Per discussio w/ PCP, [Last Name (NamePattern4) ]. [Doctor First Name 111639], reported colonoscopy revealed 12 cm colitis, showing acute chronic inflammation, ? chronic ischemia. HCT upon discharge 25 stable. require repeat outpatient colonoscopy endoscopy. . # Elevated Troponin: setting renal failure normal EKG asymptomatic. Troponins trended down, CK elevations. Likely due demand. signs HF, EF > 60%, WMA. continued ASA 81mg. . # PTST/Depression: Contact[Name (NI) ] patient's outpatient provider confirmed diagnoses PTSD Depression. Patient actively obtaining treatment OP prior admission. two episodes emotional lability crying spells. attention impaired (felt due delerium setting infection). Patient probably underlying dementia (global parenchymal atrophy periventricular white matter disease CT head), however could evaluated setting delirium. continued Celexa, Quetiapine Duloxetine home doses. ativan temporarily held due delerium restarted 2mg [Hospital1 ]. home dose 2mg [Hospital1 ] 4mg QHS, restarted prn pt remains stable. . # S/P Falls: Appears multifactorial - decreased vision, non-compliance walker, complicated oxygen tubing tripping likely acutely worsened setting impending infection prior admission. CT head c-spine without bleeding fractures. Per PT require acute level rehabilitation. . # Poor nutritional status. Pt. denies poor PO intake, Albumin 2.4. Noted poor PO intake nursing staff CCU. hx esophageal stricture. started Ensure supplementation TID. . # Code: FULL (confirmed patient) . # Communication: Patient currently odds children would prefer communication done SW - [First Name8 (NamePattern2) 51796] [Last Name (NamePattern1) 111640] [Street Address(2) 111641] [Location 17065]. counseling SW reports history domestic violence past. currently feels safe now. allowed staff speak son. Finally, Pt reports process evicted, states want family know. said case manager Elder Services helping deal eviction problem, consented SW calling (Anjale [First Name9 (NamePattern2) 111642] [Hospital1 8] [Hospital1 3494] Elder Services [Telephone/Fax (1) 16681]). Medications Admission: 1. Combivent 2. Citalopram 40 mg PO QD 3. Advair 250-50 mcg [Hospital1 ] 4. Lorazepam 2 mg PO QID 4mg QHS 5. Pantoprazole 40 mg PO BID 6. Quetiapine 300 mg PO QHS 200 mg QPM. 7. Duloxetine 30 mg PO QHS 8. Albuterol PRN 9. Mesalamine (in OMR, patient can't recall still taking) 10. Ondansetron 4 mg PO Q8 PRN 11. Aspirin 325 mg Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times day). 3. Quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QPM needed insomnia. 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO HS (at bedtime). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) needed SOB/wheezing. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice day. 9. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 10. Ativan 2 mg Tablet Sig: 1-2 Tablets PO bedtime needed insomnia, anxiety: Hold sedation. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) needed Pain. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) 2 weeks. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) 2 weeks. 16. Acetaminophen 500 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours) needed pain. 17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 18. Outpatient Lab Work CBC, Chem 10 within 1 week discharge hospital 19. Imaging Patient require CXR completion ABx results faxed PCP's office confirm resolution PNA. Discharge Disposition: Extended Care Facility: [Hospital 2251] Nursing Rehab Discharge Diagnosis: Primary: Streptococcal sepsis, multifocal community acquired pneumonia Secondary: COPD, PUD, Esophageal stricture, Anemia, PTSD Discharge Condition: Stable Discharge Instructions: admitted [Hospital1 18] severe pneumonia bacterial blood. treated intravenous antibiotics. treatment breathing improved. transitioned mouth antibiotics. course complicated worsening anemia (low blood cell count) require blood transfusions. transfusions, blood levels remained stable. require outpatient colonoscopy endoscopy. Several changes made medications, please refer list take medications prescribed. outpatient colonoscopy evaluate anemia. PCP GI doctor arrange you. Please call doctor return nearest emergency room for: recurrent nausea/vomiting, dehydration, blood vomit, chest pain, bloody stools, shortness breath, chest pain, abdominal pain, fainting, fevers, chills, cough, concerning symptoms. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2166-9-22] 12:30 Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2166-9-22] 12:30 Please follow psychiatrist, Dr. [First Name (STitle) ] [First Name9 (NamePattern2) 111643] [2168-5-27].30 am, please call confirm appointment, [Telephone/Fax (1) 111644]. Please follow primary care doctor, [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]-[Doctor First Name ], [2166-5-19] 11.30 am. Please call [Telephone/Fax (1) 14315] confirm appointment. rehabilitation time PCPs appointment, please change acommodate discharge rehabilitation. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2166-5-9]	[ "5849", "2859" ]
Admission Date: [2198-9-7] Discharge Date: [2198-9-11] Date Birth: [2117-12-20] Sex: F Service: MEDICINE Allergies: Codeine / Penicillins / Erythromycin Base / Morphine Attending:[First Name3 (LF) 800] Chief Complaint: hypotension s/p syncope Major Surgical Invasive Procedure: none History Present Illness: 80 year old woman history COPD, HTN, CRI presents syncope hypotension. reports recent past 5 days whitish phlegm turned green 1 day prior admission. denies fevers, chills night sweats. According patient awoke morning sound someone knocking door phone ringing. went get slid bed floor. denies hitting head losing consciousness. states legs gave her. report legs given 2 times past. denies dizziness, lightheadedness, palpitations. According daughter found concierge home floor vomit urine fall witnessed. denies losing urine recall vomited. EMS called. Initial vitals EMS BP 120/70 O2 sats 95% NRB. . ED, initial vs were: T97.4 HR77 BP71/31 RR20 O2sats 93 4L NC. Patient given 4L NS resuscitation. FAST scan done showing 3.8cm AAA. Given AAA hypotension, vascular surgery consult called. underwent non-contrast CT torso showed LLL infiltrate. Vascular surgery concerned AAA. given 1gm CTX, 750mg Levofloxacin 500mg Flagyl. Blood pressures improved mid-90s started trend down. R femoral CVL placed started Levophed. Lactate 2.2. found acute renal failure creatinine 2.6. Potassium 5.6. WBC 19.1 13% bands. INR noted 4.3. Blood cultures obtained. . arrival ICU complains cough without significant shortness breath. otherwise comfortable without pain. denies nausea, headache, chest pain, dysuria. Pressors weaned, patient transferred floor afebrile. . Review sytems: (+) diarrhea past week. reports diarrhea lifetime. (-) Denies fever, chills, night sweats, recent weight loss gain. Denies headache, sinus tenderness, rhinorrhea congestion. Denied chest pain tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation abdominal pain. recent change bowel bladder habits. dysuria. Denied arthralgias myalgias. Past Medical History: - Pulmonary Embolism [2-25] coumadin - Hypertension - Hypercholesterolemia - Monoclonal gammopathy - COPD - Arthritis - Gastrointestinal ulcers - Gastric esophageal reflux disease - Kidney stones 55 years ago setting pregnancy - Elevated PTH - Chronic renal insufficiency baseline 1.1 1.5 - Abdominal aortic aneurysm measuring 4.2 cm - Possible pons lacune infart noted [1-24] MR [Name13 (STitle) 2853] - Peripheral Neuropathy unclear etiology Social History: patient lives alone. divorced former husband deceased. five children. previously worked laboratory technician [Location (un) 86] State Hospital office manager. 50 pack year smoking history quit greater 25 years ago. drinks [2-17] glasses wine per day. denies use illicit drugs. Family History: patient's mother died myocardial infarction age 60. mother hyperthyroidism. patient's father myocardial infarction age [Age 90 ] benign brain tumor. sister breast cancer. daughter juvenile rheumatoid arthritis. family history gastric disorders kidney stones. Physical Exam: Vitals: T: 98.4 BP: 118/80 P: 81 R: 18 O2: 93% RA General: Alert, oriented, elderly female, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat, LAD Lungs: decreased breath sounds left side, otherwise clear CV: Regular rate rhythm, normal S1 + S2, 2/6 systolic ejection murmur LUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis, 1+ peripheral edema bilaterally, former site femoral catheter (now withdrawn) right C/D/I Neuro: A&O x 3, CNII-XII grossly intact. Pertinent Results: Labs admission: [2198-9-7] 07:31PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2198-9-7] 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2198-9-7] 07:31PM URINE RBC-0-2 WBC-[7-26]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2198-9-7] 06:30PM URINE HOURS-RANDOM CREAT-96 SODIUM-27 POTASSIUM-98 CHLORIDE-62 [2198-9-7] 06:30PM URINE OSMOLAL-440 [2198-9-7] 03:51PM K+-5.6* [2198-9-7] 12:42PM LACTATE-2.2* [2198-9-7] 12:20PM GLUCOSE-144* UREA N-49* CREAT-2.6# SODIUM-137 POTASSIUM-7.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [2198-9-7] 12:20PM estGFR-Using [2198-9-7] 12:20PM ALT(SGPT)-47* AST(SGOT)-69* ALK PHOS-65 TOT BILI-0.3 [2198-9-7] 12:20PM LIPASE-18 [2198-9-7] 12:20PM cTropnT-<0.01 [2198-9-7] 12:20PM ALBUMIN-3.4* [2198-9-7] 12:20PM WBC-19.1# RBC-3.84 HGB-10.9* HCT-33.2* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7 [2198-9-7] 12:20PM NEUTS-81* BANDS-13* LYMPHS-1* MONOS-4 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2198-9-7] 12:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2198-9-7] 12:20PM PLT SMR-NORMAL PLT COUNT-248 [2198-9-7] 12:20PM PT-40.5* PTT-41.4* INR(PT)-4.3* Discharge: [2198-9-11] 05:15AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.0* Hct-29.9* MCV-84 MCH-28.1 MCHC-33.5 RDW-14.3 Plt Ct-260 [2198-9-11] 05:15AM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [2198-9-11] 05:15AM BLOOD ALT-31 AST-17 [2198-9-11] 05:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.4* Radiology: CHEST (PORTABLE AP) Study Date [2198-9-7] 12:18 PM IMPRESSION: Mild central vascular congestion without overt failure. Bibasilar atelectasis. Increased opacity retrocardiac left lower lobe may reflect underlying pneumonia aspiration. Correlate clinically. CT CHEST W/O CONTRAST Study Date [2198-9-7] 12:34 PM LUNG BASES: consolidation ground-glass opacification superior segment left lower lobe, well portions posterior basal segment right lower lobe. CT HEAD W/O CONTRAST Study Date [2198-9-7] 12:33 PM IMPRESSION: acute intracranial process. CT ABDOMEN W/O CONTRAST Study Date [2198-9-7] 12:34 PM IMPRESSION: 1. evidence rupture patient's 3.8-cm abdominal aortic aneurysm. Stability size maintained. 2. Area density within left breast lucent center, may represent intramammary lymph node, fat necrosis, oil cyst. Recommend correlation mammogram. 3. Stable appearance adrenal nodule 5 years, described above. 4. Status post cholecystectomy, stable expected dilatation common bile duct. 5. Diverticulosis evidence diverticulitis. US ABD LIMIT, SINGLE ORGAN PORT Study Date [2198-9-8] 1:54 PM IMPRESSION: Stable common bile duct approximately 9 mm. liver echotexture normal underlying suggestion cirrhosis parenchymal disease. mass lesion identified. intrahepatic biliary dilatation. interval development small right pleural effusion. Known abdominal aortic aneurysm stable size since yesterday. BILAT EXT VEINS US Study Date [2198-9-8] 1:54 PM IMPRESSION: DVT either upper extremity. Brief Hospital Course: 80 year old woman hx PE coumadin, HTN presents syncope, hypotension likely PNA concerning sepsis. . 1. Hypotension: Likely sepsis given chest CT findings PNA, elevated WBC cough. fevers. received 4L NS ED continued appear clinically dry. Volume resuscitation continued MICU along levophed weaned 24 hours. PNA treatment begun ceftriaxone levofloxacin, later switched cefpodoxime levofloaxin, total 8 day course. Patient's blood pressure floor normotensive, although continued hold home medications HCTZ, Amlodipine, Benzepril, discharged instructions follow-up PCP resume medications. . 2. Acute Renal Failure: Prior kidney function 1.2. Patient made good urine throughout hospitalization. creatinine peaked 2.6 trended nadir 1 upon discharge volume resuscitation holding nephrotoxic meds. 3. UTI: [2198-9-7], patient noted UTI urine culture E. Coli, sensitive ceftriaxone. patient treated PNA ceftriaxone levofloxacin, change antibiotic regimen, appropriately cover uncomplicated UTI. . 3. Hyperkalemia: Felt secondary acute renal failure setting taking potassium triamterene benazepril. ECG without peaked waves. Offending meds held hospitalization, held patient follow-up primary care physician. [Name10 (NameIs) ] patient's hyperkalemia improved aggressive IV fluid resusitation, discharge K 4.0. . 4. Syncope: Likely hypotension, hypovolemia. concerning patient lost urine signs seizure activity stay MICU floor. patient monitored tele without event. EEG done. . 5. Elevated INR: Likely due infection coumadin use. signs active bleeding. Would expect INR rise recent antibiotics. Coumadin initially held restarted prior discharge, INR discharge 2.7. . Code: Full (discussed patient) Medications Admission: Hydrochlorothiazide 25 mg Tab PO daily Bisoprolol Fumarate 2.5 mg Tab PO daily Omeprazole 40 mg Cap, Delayed Release 1 tab PO Daily Klor-Con 8 mEq Tab 1 tab PO BID Amlodipine 5 mg Tab 1 tab PO daily Benazepril 40 mg Tab PO daily Multivitamin Tab 1 tab PO daily Triamterene 50 mg PO daily Simvastatin 80mg PO daily Trazadone 100-150mg PO qHS PRN - taken past day perhaps monday, tuesday wednesday Coumadin alternating 1.5mg 2mg week Gabapentin 100mg PO TID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Sepsis secondary Community Acquired Pneumonia Urinary Tract Infection . Secondary Diagnoses: Hx Pulmonary Embolism Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted ICU low blood pressure setting pneumonia. treated IV fluids antibiotics symptoms improved. complete total 8 days antibiotics, follow-up PCP. . made following changes home medications: -Start Cefpodoxime - continue 6 days end [2198-9-16] -Start Levofloxacin - continue 6 days end [2198-9-16] (this every-other-day medication). -STOP Hydrochlorothiazide, Amlodipine, Benazepril, Triamterene Klor-Con see PCP [Name9 (PRE) 2974]. decide resume medications. -CHANGE Coumadin 1.5 Mg daily week - please INR drawn tomorrow, Wednesday 28th PCP's office. Followup Instructions: Please INR drawn tomorrow PCP's office. appointment see PCP [Name9 (PRE) 2974]: Name: [Last Name (LF) 7726],[First Name3 (LF) 177] A. When: FRIDAY, [2198-9-14]:30 Address: [Street Address(2) 7727],2ND FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 7728] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "5849", "486", "5990", "2720" ]
Admission Date: [2117-7-22] Discharge Date: [2117-7-31] Date Birth: [2036-6-4] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 943] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical Invasive Procedure: EGD Central venous line access History Present Illness: 81 year old female presented outside hospital 3 weeks prior admission nausea, vomiting, diarrhea, abdominal pain. diagnosed cirrhosis unknown etiology; negative hepatitis, hemachromatosis, history alcoholism. symptoms improved discharged. presented [Hospital1 18] similar symptoms. CT scan abdomen demonstrated complete thrombosis SMV partial thrombosis main PV intrahepatic left right portal veins multiple abnormal loops small bowel pelvis wall thickening. Patient started heparin drip. Foley & NGT placed. received vancomycin & Zosyn ED, switched Cipro Flagyl admission ICU. Past Medical History: hypertension cirrhosis osteoarthritis dyslipidemia h/o ureteral stone seborrheic keratosis thrombocytopenia appendectomy herpes zoster GERD osteopenia depression hip replacement cellulitis Social History: denies EtOH, tobacco, illicit drug use. denies herbal over-the-counter medications. Family History: aunt ovarian ca daughter breast ca 50s family history liver disease Physical Exam: per Dr. [Last Name (STitle) ] initial presentation: 98.1 65 145/61 20 98% 4L gen: minimally response CV RRR pulm: CTAB abd: soft, nondistended, mildley tender right rectal: heme pos Pertinent Results: Admission labs: 137 105 15 -------------< 117 3.7 21 0.7 Ca: 9.4 Mg: 1.7 P: 2.6 ALT: 25 AP: 271 Tbili: 2.0 Alb: 3.2 AST: 32 LDH: Dbili: TProt: [Doctor First Name ]: 52 Lip: 54 . 12.9 9.9 >-----< 165 41 N:85.3 Band:0 L:9.7 M:3.7 E:0.9 Bas:0.4 . Trends discharge labs: [2117-7-31] 06:45AM BLOOD WBC-5.7 RBC-3.16* Hgb-10.1* Hct-30.7* MCV-97 MCH-32.0 MCHC-32.9 RDW-16.2* Plt Ct-PND [2117-7-26] 05:06AM BLOOD PT-19.5* PTT-67.8* INR(PT)-1.9* [2117-7-27] 06:00AM BLOOD PT-21.1* PTT-62.3* INR(PT)-2.0* [2117-7-28] 05:21AM BLOOD PT-21.5* PTT-93.3* INR(PT)-2.1* [2117-7-29] 05:03AM BLOOD PT-20.7* PTT-33.5 INR(PT)-2.0* [2117-7-30] 06:15AM BLOOD PT-20.6* PTT-33.0 INR(PT)-2.0* [2117-7-31] 06:45AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-134 K-3.4 Cl-98 HCO3-33* AnGap-6* [2117-7-22] 06:05AM BLOOD ALT-25 AST-32 AlkPhos-271* Amylase-52 TotBili-2.0* [2117-7-23] 02:15AM BLOOD ALT-17 AST-26 LD(LDH)-231 AlkPhos-193* Amylase-36 TotBili-0.8 [2117-7-24] 01:57AM BLOOD ALT-17 AST-21 LD(LDH)-202 AlkPhos-171* Amylase-28 TotBili-0.6 [2117-7-25] 05:30AM BLOOD ALT-15 AST-21 LD(LDH)-191 AlkPhos-164* Amylase-27 TotBili-0.7 [2117-7-26] 05:06AM BLOOD ALT-15 AST-25 AlkPhos-159* Amylase-46 TotBili-0.8 [2117-7-27] 06:00AM BLOOD ALT-13 AST-26 LD(LDH)-213 AlkPhos-151* Amylase-45 TotBili-0.8 [2117-7-28] 05:21AM BLOOD ALT-16 AST-31 AlkPhos-156* TotBili-1.0 [2117-7-29] 05:03AM BLOOD ALT-15 AST-34 AlkPhos-179* TotBili-0.8 [2117-7-27] 06:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-2.8 Mg-2.1 [2117-7-24] 06:21AM BLOOD Lactate-1.4 . CT Abd/Pelvis ([2117-7-22]) IMPRESSION: 1. Complete thrombosis superior mesenteric vein partial thrombosis main portal vein intrahepatic left right portal veins. 2. Multiple abnormal loops small bowel within pelvis wall thickening. likely represents venous congestion thrombosis mesenteric veins. enterocolitis (inflammatory/infectious) secondary thrombosis mesenteric veins also possibility. mesenteric arteries patent; however, mesenteric ischemia venous congestion cannot excluded. 3. Shrunken, nodular liver, esophageal varices ascites, compatible cirrhosis. . CT Abd/Pelvis ([2117-7-27]) IMPRESSION: 1. Stable thrombosis portal vasculature including partial thrombosis main portal vein, complete thrombosis left portal vein, partial thrombosis right portal vein, complete thrombosis superior mesenteric vein. 2. Improving multiple small bowel loops decreased wall thickening dilatation. 3. Stable cirrhotic liver. 4. Markedly increased ascites. . EGD: Impression: Grade 1 varices lower third esophagus Portal Hypertensive Gastropathy - oozing blood causing melena. Otherwise normal EGD second part duodenum Recommendations: Requires: 1) Protonix- 40mg [Hospital1 ] 2) Carafate - 1gram qid . Micro: c diff neg stool cx neg blood cx ngtd Brief Hospital Course: 81yo woman cirrhosis SMV thrombosis. Hospital course problem: . #Complete SMV partial portal vein thrombosis. SMV portal vein thromboses demonstrated CT [7-22] repeated [7-27] showing little change. Hepatobiliary Surgery consulted urgently ED management SMV thrombosis ischemic bowel. Serial abdominal exams benign. Lactate peaked 1.5 [7-22]. episodes melena [7-17], remained otherwise asymptomatic. ICU close monitoring transferred floor [7-25]. NGT removed Coumadin started. [7-26], diet advanced transferred Hepatology management newly diagnosed cirrhosis. continued heparin coumadin INR 2.0 two consecutive days. received coumadin follows: 1mg, 1mg, 1mg, 2mg, 2mg, 2mg discharged 2mg daily. HCT remained stable. followup Dr. [Last Name (STitle) ] liver clinic. [Last Name (STitle) 18303] INR [2-20]. . #GI Bleeding Patient guaiac positive stools underwent EGD assess varices showed active bleeding portal gastropathy thought explain patient's melena. Melena may also come venous congestion small bowel result SMV thrombosis. Repeat CT scan showed resolving venous congestion. HCT dropped 5.5 points 41 34.5 HD0 HD1 30 HD4, remained stable this, without melena. Ms. [Known lastname 73649] spotting red blood pads toilet paper thought causing persistant guaiac positive stools. Exam confirmed presence hemorrhoids also raised possibility vaginal bleeding, investigated outpatient. Colonoscopy deferred given likely friable colon setting thrombosis. BRBPR, recommend checking hematocrit [Known lastname ] >28. less 28, discuss patient's PCP stopping coumadin need eval. terms possible vaginal bleeding, recommend outpt gynecology appt. continued nadolol PPI sucralfate. . #Cirrhosis/Edema/abdominal pain Etiology cirrhosis remains uncertain. Report investigations OSH ruled common viral autoimmune etiologies, genetic causes would unlikely present 81years age. NASH remains possibility, investigated outpatient hepatology follow arranged Ms. [Known lastname 73649]. experienced significant fluid retention ascites lower extremity edema, weight increasing approximately 4kgs. Lasix Aldactone, lower extremity edema improved significantly ascites persistant. Ascites caused intermittent band like upper abdominal pain mostly controlled oxycodone occassionally required 0.5mg dilaudid IV. time discharge, pain controlled oral medications alone. . # HTN: regulated nadolol, spirono, lasix. continue HCTZ . # Depression: sertraline . # Activity: seen PT. able ambulate assist. . # Code: Full . # Contact: daughter [Name (NI) ]: [Telephone/Fax (1) 100371] Medications Admission: lorazepam, Darvocet, Fosamax, HCTZ, MVI, Propoxyphene, ranitidine, sertraline, Zocor Discharge Medications: 1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times day). Disp:120 Tablet(s) Refills:2 7. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO every six (6) hours needed pain. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed Pain 1 weeks. Disp:20 Tablet(s) Refills:0 9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): please adjust per recommendations PCP. [Name10 (NameIs) 18303] INR [2-20]. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 9475] Care Center - [Location (un) 3146] Discharge Diagnosis: Primary: - SMV thrombosis - Cirrhosis - Portal gastropathy Secondary: - GERD - arthritis - HTN - Hyperchol - thrombocytopenia Discharge Condition: well. Able ambulate assist Discharge Instructions: admitted abdominal pain noted SMV thrombosis. clot vein near liver. also cirrhosis fluid overload. treated ICU stabilized. continued heparin started coumadin keep blood thin. also performed EGD look bleeding stomach. remained stable. . Please take medications instructed. Please keep followup appts. important coumadin level checked Monday followed closely PCP. . Please contact PCP [Name (NI) ] experience worsening shortness breath, chest pain, abdominal pain, fevers, blood loss. . described possible vaginal bleeding. discuss PCP possibly see gynecologist. Followup Instructions: Please followup Dr. [Last Name (STitle) ] Thursday [8-5] 11:30am. office [Telephone/Fax (1) ] . Please followup Dr. [Last Name (STitle) ] [8-24] @ 12:15pm. may reach ([Telephone/Fax (1) 1582].	[ "4019" ]
Admission Date: [2165-8-2] Discharge Date: [2165-8-5] Date Birth: [2098-2-18] Sex: Service: MED Allergies: Patient recorded Known Allergies Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Dark blood G-tube Major Surgical Invasive Procedure: EGD-ulcer distal esophagus active bleeding. s/p clipping vessel good homostasis. History Present Illness: 67 yo h/o CAD, recently admitted [6-21] [7-25] presented severe headache, CT notable large intracranial bleed. Found vertebrobasilar aneurysm, s/p coiling stenting, ventriculostomy. Course complicated L sided PE treated heparin. Hospital course also complicated CHF, failure wean vent, s/p trach, PEG placment. Patient eventually weaned vent end hospitalization. discharge, patient able open eyes stimulation, spontaneous movment R side. Patient discharged [Month/Day (4) ], plavix, heparin gtt. Pt. sent [Hospital3 ]. Came ED [7-26] hypotension , sbp 80s, responded IV boluses, cleared N-[Doctor First Name ] (no change). [8-1], patient noted 50 cc dark blood G-tube rehab. ED, patient afebrile, hr-82, bp-121/64. Dark blood failed clear lavage. GI subsequently consulted. ED, hct-30, INR-2.9. Got vit K 5mg sq, IV protonix, 4 units FFP, 2 large [Last Name (un) ] IVs placed. CXR showing CHF opacities effusions. EKG showing NSR 90 bpm, nl axis, IVCD L bundle pattern, 1-[Street Address(2) 1766] depr V3-6 (old) TWI V3-6, L (old). Past Medical History: -CAD, s/p MI, CABG x 2 '[50] '[62], multiple stents -htn -s/p MV annuloplasty '[62] -s/p AICD -s/p intracranial bleed [5-28], per HPI -mult L sided PEs ([6-28]) -h/o hyponatremia -VRE pos -CHF - [6-28] echo EF 30%, moderate regional LV systolic dysfunction near AK inferior inferolateral walls, sever HK anterolat. wall. Physical Exam: 97.6 BP 121/64 P82 RR30 100% 4LNC Gen: Minimally resonsive, unable follow commands HEENT: NC/AT, PERRL 2mm bilaterally Lungs: +upper airway sounds, crackles, wheezing, good air movement CV: RRR, nl S1, S2, murmurs Abd: Soft, NTND, withdraw deep palpation. +G-tube Ext: edema, clubbing, cyanosis Neuro: responds minimally verbal stimuli, withdraws pain. Pertinent Results: [2165-8-5] 04:49AM BLOOD WBC-9.2 RBC-3.52* Hgb-10.6* Hct-32.2* MCV-92 MCH-30.1 MCHC-32.9 RDW-15.6* Plt Ct-400 [2165-8-4] 04:34PM BLOOD Hct-34.2* [2165-8-3] 11:41PM BLOOD Hct-32.5* [2165-8-3] 04:00AM BLOOD WBC-10.0 RBC-3.51* Hgb-10.6* Hct-31.5* MCV-90 MCH-30.4 MCHC-33.8 RDW-15.6* Plt Ct-379 [2165-8-2] 10:42PM BLOOD Hct-28.3* [2165-8-2] 08:13PM BLOOD Hct-29.2* [2165-8-2] 10:03AM BLOOD Hct-23.7# [2165-8-5] 04:49AM BLOOD PT-14.7 PTT-56.5* INR(PT)-1.4 [2165-8-4] 08:16PM BLOOD PTT-39.1* [2165-8-4] 04:32AM BLOOD PT-14.7* PTT-24.2 INR(PT)-1.4 [2165-8-3] 04:00AM BLOOD PT-15.2* PTT-26.1 INR(PT)-1.5 [2165-8-2] 10:40AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.8 [2165-8-2] 04:15AM BLOOD PT-20.8* PTT-37.0* INR(PT)-2.9 [2165-8-5] 04:49AM BLOOD Glucose-117* UreaN-22* Creat-0.4* Na-143 K-3.9 Cl-108 HCO3-27 AnGap-12 [2165-8-2] 04:15AM BLOOD Glucose-113* UreaN-26* Creat-0.6 Na-133 K-5.3* Cl-96 HCO3-29 AnGap-13 [2165-8-4] 04:32AM BLOOD ALT-28 AST-30 AlkPhos-124* [2165-8-3] 06:45PM BLOOD CK-MB-3 cTropnT-0.07* [2165-8-2] 10:43PM BLOOD CK-MB-4 cTropnT-0.05* [2165-8-2] 04:00PM BLOOD CK-MB-3 cTropnT-<0.01 Brief Hospital Course: 1)Upper GI bleed: Patient coumadin recent hx PE received 4 units FFP vit K EW correct INR. Coumadin held intinitally possible active bleed. GI consulted EGD done [2165-8-2] showed ulcer distal esophagus active bleeding site. Successful clipping vessel achieved using Resolution Endoclip device injected epinephrine hemostasis. Patient received total 3 units PRBC. Patient continued PPI prophylaxis serial hematocrit done remained stable (Hct>30). 2)Neuro: Patient hx intracranial bleed s/p basilar stent. Patient Plavix [Date Range ] post-stent prophylaxis. Patient remained lethargic baseline. able follow simple commands times, moving hands feet occasionally giving verbal response. Per family member, patient appears alert before. Neurosurgery following patient strongly urged hold Coumadin risk re-bleeding intracranially. discussion Dr. [Last Name (STitle) 1132] neurosurgery, decided discharge patient Lovenox. 3)A-fib: EGD proceduse, clipping bleeding vessel done epinephrine injected site. Right epinephrine injected, went rapid afib 150's ST depressions. given total 10 mg lopressor decrease HR 120's-130's. 10 mg IV diltiazem, HR came 90's-100's BP dropped 80's briefly. MI ruled serial cardiac enzymes given 25 mg lopressor. Patient remained sinus tachycardia, lopressor titrated 50 mg tid. Patient show good response IV diltiazem 10 mg. 4)PE prophylaxis: Patient initially Coumadin 12.5 mg qd Dalteparin 7500 units [Hospital1 ], held due GI bleed INR 2.9 PTT 37. Neurosurgery seen patient strongly discouraged discontinuing Coumadin due recent history intracranial bleed. However, patient PE risk another thrombotic event. discussion neurosrugery attending Dr. [Last Name (STitle) 1132], decided discharge patient Lovenox. 5)ID: [8-4] sputum gram stain showed gram positive cooci rhonchi exam. CXR intially appeared LLL opacity Vancomycin 1 g q12 started. However reviewing film team [2165-8-5], CXR consistent fluid overload effusion consolidation. Since patient afebrile normal WBC showing symptom pneumonia, Vancomycin discontinued. Medications Admission: protonix 40 qd, senna 2 [Hospital1 ], epo [2161] units q Tu/Sat, amantidine 100 [Hospital1 ], coumadin 12.5 [Last Name (LF) ], [First Name3 (LF) ] 325 qd, lopresor 25 [Hospital1 ], dalteparin 7500 units [Hospital1 ] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 4. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Esophageal bleed Atrial fib Intracranial bleed s/p stent vertebrobasilar aneurysm Hx pulmonary embolism CAD CHF Discharge Condition: Hemodynamically stable, active bleeding. Discharge Instructions: Patient needs seek medical attention (ED, PCP), bloody vomit, bloody stool, blood G-tube, dyspnea, chest pain, new neurological deficit, fever/chills. Followup Instructions: Patient needs seen PCP soon possible appointment neurosurgery following date. Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) ], MD Where: LM [Hospital Unit Name 12006] Phone:[Telephone/Fax (1) 3666] Date/Time:[2165-8-9] 2:30 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2165-8-5]	[ "4280", "2851", "4019" ]
Admission Date: [2103-7-24] Discharge Date: [2103-7-26] Service: CHIEF COMPLAINT: patient 78 year old female past medical history significant obstructive sleep apnea, pulmonary hypertension, chronic hypercapnic hypoxemic respiratory failure, presented worsening shortness breath decreased oxygen saturation. HISTORY PRESENT ILLNESS: patient 78 year old woman history long-standing obstructive sleep apnea subsequent pulmonary hypertension. Two days prior admission, patient reported experiencing gradual worsening shortness breath. morning admission, patient's daughter found patient severely short breath, cyanotic called EMS. EMS arrived, patient noted room air oxygen saturation 60% range noted tachypneic respiratory rate 40s. Upon arrival [Hospital1 69] Emergency Department, patient noted cyanotic vital signs showed heart rate 85, blood pressure 175/77, respiratory rate 32, saturating 97% 100% nonrebreather face mask. denied chest pain time Emergency Department presentation. denied [Last Name (LF) ], [First Name3 (LF) 691] fever chills. denied nausea vomiting. abdominal pain. denied urinary symptoms, denied symptoms paroxysmal nocturnal dyspnea. patient placed full face mask BIPAP admitted Medical Intensive Care Unit monitoring respiratory status. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. diagnosed least five years prior time admission sleep studies performed [2098-2-17], showed 43 hypopneas oxygen saturation 70s. data records provided patient's primary pulmonologist, Dr. [Last Name (STitle) 10132], [Hospital3 ] Medical Center. home, patient wore CPAP four six hours every night received oxygen via nasal cannula rate 2 2.5 liters per minute day. 2. Chronic hypercapnic hypoxemic respiratory failure. patient room air oximetry studies performed [2102-7-21], outpatient hospital showed spent approximately 63% time oxygen saturation 90s, 24% time oxygen saturation 80s 5% time oxygen saturation 70s. 3. Restrictive lung disease. 4. Pulmonary hypertension. 5. Hypertension. 6. Coronary artery disease, status post coronary artery catheterization [2097-10-18], showed clean coronary arteries. 7. Status post inferior myocardial infarction approximately fifteen years ago. 8. Inguinal hernia. 9. Chronic anemia thought due Vitamin B12 deficiency. MEDICATIONS ADMISSION: 1. Lasix 40 mg q.d. 2. Atenolol 25 mg day. 3. Nitroglycerin patch 0.4 mg transdermal patch applied day. 4. Carvedilol 3.125 mg day. 5. Allopurinol. ALLERGIES: Reported allergies Penicillin Streptomycin. FAMILY HISTORY: assessed. SOCIAL HISTORY: patient Russian speaking woman come United States [Country 532] eight years ago. lives alone [Location (un) 86] area two daughters lived nearby. history tobacco use history exposure asbestos known industrial agents. PHYSICAL EXAMINATION: examined patient, vital signs revealed heart rate 48, blood pressure 89/48, respiratory rate 26, oxygen saturation 92% BIPAP face mask pressure support 15, PEEP 5 FIO2 40%. noted awake, alert able respond questions help translation. skin examination notable pallor cyanosis. Examination jugular venous distention revealed jugular venous pulse 9.0 centimeters. chest examination showed diffusely decreased breath sounds, decreased left side right side, however, wheezes crackles noted. cardiac examination revealed bradycardic heart rate regular rhythm harsh IV/VI systolic murmur heard across precordium, occasional S3 rubs. abdominal examination revealed normoactive bowel sounds, obese soft abdomen, nontender. costovertebral angle tenderness. Examination extremities showed dorsalis pedis pulses 1+ bilaterally. extremities warm. 1+ bilateral lower extremity edema. also noted bilateral calf tenderness. LABORATORY DATA: admission, sodium 142, initial potassium 7.0 hemolyzed specimen repeat potassium 4.9, chloride 96, bicarbonate 37, blood urea nitrogen 23, creatinine 0.8, glucose 151. complete blood count revealed white blood cell count 6.9, hematocrit 37.5, platelet count 357,000. white blood cell count differential included 72% polys, 20 lymphocytes 7 monocytes. coagulation panel showed prothrombin time 13.0, partial thromboplastin time 29.1 INR 1.2. Initial CK level 65. Electrocardiogram showed normal sinus rhythm rate 78 beats per minute right axis deviation right bundle branch block unchanged previous electrocardiogram provided outside hospital. chest x-ray showed opacification right mediastinal border prominent pulmonary vasculature focal consolidation. HOSPITAL COURSE: Emergency Department, initial arterial blood gas performed patient 100% nonrebreather face mask. blood gas revealed pH 7.19, pCO2 122, pO2 150. patient placed face mask 50% FIO2, repeat blood gas showed pH 7.13, pCO2 137, pO2 132. patient given single dose Levofloxacin Emergency Department treat community acquired pneumonia. also given intravenous Solu-Medrol treat underlying bronchospastic component contributing pulmonary decompensation. given 1 mg Morphine Sulfate also Nitroglycerin paste Emergency Department. time Emergency Department presentation, patient reported DNR/DNI code status. Therefore, intubation attempted patient. Instead, full face mask preferred method oxygen delivery admitted Medical Intensive Care Unit monitoring oxygenation ventilatory status. evening admission, ultrasound studies lower extremities performed revealed evidence deep vein thrombosis. patient also diuresed Lasix, received total 100 mg intravenous Lasix Emergency Department additional 40 mg Lasix admission Intensive Care Unit. produced net diuresis negative two liters evening admission. antibiotics held time patient afebrile elevated white blood cell count low clinical suspicion pneumonia. steroids also held. Overnight, patient's oxygenation ventilatory status improved somewhat based repeat arterial blood gas analysis. placed nasal CPAP overnight. subsequently ruled myocardial infarction via cardiac enzymes. [2103-7-25], hospital day two, echocardiogram obtained order assess possible role diastolic congestive heart failure contributing pulmonary edema patient's shortness breath. Following echocardiogram performed bedside, patient experienced desaturation oxygen saturation noted 30 40% range. patient noted profoundly cyanotic also began report left sided chest pain. electrocardiogram obtained showed changes suggestive acute ischemia. Stat portable chest x-ray also showed acute change prior chest x-rays. time desaturation event, patient nasal CPAP ultimately placed full face mask BIPAP, patient's oxygen saturation returned 80% range. echocardiogram ultimately showed ejection fraction greater 55%, mild symmetric left ventricular hypertrophy. left atrium right atrium noted dilated. overall decrease right heart function severe pulmonary artery systolic hypertension. Although previously obtained lower extremity ultrasounds revealed deep vein thrombosis, continued entertain diagnosis pulmonary embolism. time Emergency Department presentation, patient unable lie flat without becoming profoundly short breath. Therefore, unable send patient CT angiogram study prove presence pulmonary embolism. However, desaturation event, decision made empirically anticoagulate patient Heparin. Levofloxacin also restarted treat presumptive pneumonia. day initial blood culture taken Emergency Department returned positive gram positive cocci pairs clusters one two bottles patient begun Vancomycin. patient subsequently remained stable respiratory standpoint noted intermittent bradycardia heart rates 30 40s transient associated hypotension. Atropine placed patient's bedside. morning [2103-7-26], patient restarted Solu-Medrol treat possible underlying component bronchospastic disease decision made obtain bedside abdominal ultrasound evaluate question pleural effusion right lung base seen serial chest x-rays. However, ultrasound could obtained, patient experienced another desaturation event early afternoon [2103-7-26]. accompanied bradycardia eventually cardiopulmonary arrest patient ultimately succumbed declared deceased afternoon [2103-7-26]. DR.[Last Name (STitle) ],[First Name3 (LF) ] R. 12-207 Dictated By:[Doctor Last Name 35468] MEDQUIST36 D: [2103-7-27] 14:50 T: [2103-7-30] 17:13 JOB#: [Job Number 35469]	[ "486", "4280" ]
Admission Date: [2196-6-10] Discharge Date: [2196-6-14] Date Birth: [2145-1-10] Sex: Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Motor vehicle crash Major Surgical Invasive Procedure: None History Present Illness: 51M restrained driver s/p T-bone motor vehicle crash + LOC. taken area hospital found mulitple injuries transported [Hospital1 18] care. Past Medical History: HTN, kidney stones, GERD Family History: Noncontributory Physical Exam: Upon exam: Gen: WD/WN, comfortable, NAD. HEENT: NCAT Neck: cervical collar. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm well-perfused. Neuro: Mental status: Awake alert, cooperative exam, normal affect. Orientation: Oriented person, place, date. Language: Speech fluent good comprehension repetition. Naming intact. dysarthria paraphasic errors. Cranial Nerves: I: tested II: Pupils equally round reactive light, 3.5 2 mm bilaterally. Visual fields full confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength sensation intact symmetric. VIII: Hearing intact voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk tone bilaterally. abnormal movements, tremors. Strength full power [5-10] throughout. pronator drift Sensation: Intact light touch throughout. Reflexes: B Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal rapid alternating movements Pertinent Results: [2196-6-10] 11:38PM GLUCOSE-158* UREA N-14 CREAT-0.8 SODIUM-141 POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16 [2196-6-10] 11:38PM WBC-17.6* RBC-4.61 HGB-14.1 HCT-40.0 MCV-87 MCH-30.6 MCHC-35.2* RDW-14.4 [2196-6-10] 11:38PM PLT COUNT-302 [2196-6-10] 11:38PM PT-13.1 PTT-21.5* INR(PT)-1.1 [2196-6-10] 08:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2196-6-10] 08:54PM WBC-23.7* RBC-5.03 HGB-15.2 HCT-44.6 MCV-89 MCH-30.1 MCHC-34.0 RDW-14.0 CT Head [2196-6-10] IMPRESSION: 1. Longitudinal left temporal bone skull base fracture appears spare carotid canal. fracture traverse middle ear ossicular disruption cannot excluded. 2. Small left posterior frontal subarachnoid hemorrhage. 3. Asymmetric left occipital hypoattenuation suggested acute infarct cannot excluded. Recommend MRI/MRA versus CTA evaluation CT C-spine [2196-6-10] IMPRESSION: Non-displaced fracture right intra-articular portion C7, described. fracture listhesis. CT Chest/Abdomen/Pelvis [2196-6-10] IMPRESSION: 1. Moderately large mesenteric hematoma may represent significant vascular injury small bowel. 2. Left inferior pole renal infarct. left renal artery appears intact, dissection cannot excluded CTA recommended evaluation. 3. Nondisplaced right first rib fracture. 4. Bilateral transverse process fractures L3 left transverse process fracture L4. 5. Bibasilar consolidations lingular consolidation likely represent atelectasis, however component aspiration excluded. 5. Right adrenal nodule, small characterize. CTA Head/Neck [2196-6-11] IMPRESSION: 1. Left parietal subarachnoid hemorrhage less apparent. new hemorrhage. 2. Normal CT angiography neck. 3. Normal CT angiography head. 4. Fracture right C7 visualized extending transverse foramen, vertebral artery enter foramen transversarium level interrupts C6 level. Right first rib fracture identified. CT Right arm [2196-6-11] FINDINGS: distal humerus normal appearance. evidence acute fracture. Brief Hospital Course: admitted Trauma service. Neurosurgery Orthopedic spine consulted injuries. left parietal subarachnoid hemorrhage managed non operatively; serial head CT scans performed remained stable. follow Dr. [First Name (STitle) ] 4 weeks repeat head imaging. noted skull base fracture left temporal bone; dedicated CT temporal bone done require outpatient follow ENT audiogram. spine injuries also managed non operatively hard cervical collar worn times lumbar corset worn bed. follow 2 weeks Dr. [Last Name (STitle) 363], Orthopedic Spine surgery. Orthopedics consulted concern possible right humerus fracture given patient increased complaints right arm pain movement upon palpation. CT arm performed fracture identified. felt pain experiencing likely related cervical spine fracture dermatome path followed along arm. started Neurontin, Ultram prn Percocet pain reported helpful. evaluated Physical therapy discharged home hospital day 5 specific instructions follow up. Medications Admission: hctz, nexium, simvastatin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day) needed constipation. 2. Milk Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) needed constipation. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) needed pain. Disp:60 Tablet(s) Refills:0 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed pain: exceed 2,000mg day. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times day). Disp:90 Capsule(s) Refills:2 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain. Disp:90 Tablet(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Small subarachnoid hemorrhage Basilar skull fracture Left temporal bone fracture C7 facet fracture Bilateral tranverse process fractures L3 & left L4 Mesenteric hemotoma Neuropathic pain Discharge Condition: Hemodynamically stable, tolerating regular diet, pain adequately controlled. Discharge Instructions: must continue wear cervical collar times next 10 weeks. need wear corsett brace bed lumbar fractures. Wear sling comfort left arm. Return Emergency room develop fevers, chills, headache, weakness/numbness extremities, shortness breath, chest pain, nausea, vomiting, diarrhea, loss bowel bladder function and/or symptoms concerning you. Followup Instructions: Follow next week [Hospital ] clinic, need audiogram appointment well. Call [Telephone/Fax (1) 41] appointment. Follow 2 weeks Dr. [Last Name (STitle) 363], Orthopedics Spine Surgery spine fracture. call [Telephone/Fax (1) 3573] appointment. Follow 4 weeks Dr. [First Name (STitle) ], Neurosurgery subarachnoid hemorrhage. Call [Telephone/Fax (1) 1669] appointment. Inform office need repeat head CT scan appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2196-6-22]	[ "4019", "2724" ]
Admission Date: [2109-7-21] Discharge Date: [2109-8-13] Date Birth: [2053-6-5] Sex: F Service: [Doctor Last Name 1181] MEDICINE HISTORY PRESENT ILLNESS: 56-year-old white female history right frontal craniotomy [2109-7-1], dysembryoplastic angioneural epithelial lesion features oligodendroglioma started Dilantin postoperatively seizure prophylaxis subsequently developed eye discharge seen optometrist treated sulfate ophthalmic drops. patient developed oral sores rash chest night admission rapidly spread face, trunk, upper extremities within last 24 hours. patient unable eat secondary mouth pain. fevers, weakness, diarrhea. genital morning [7-20]. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Benign right frontal cystic tumor status post right frontal craniotomy [2109-7-1]. ALLERGIES: KNOWN DRUG ALLERGIES. MEDICATIONS: Lipitor, Tylenol Codeine, Dilantin, previously Decadron q.i.d. tapered one week discontinued week ago. SOCIAL HISTORY: patient lives husband, daughter, son. [Name (NI) ] smoking ethanol use history. PHYSICAL EXAMINATION: Vital signs: T-max 104.3??????, currently 100.8??????, heart rate 107-110, blood pressure 110/27, respirations 15-20, oxygen saturation 98% room air. General: patient alert, ill-appearing woman postsurgical occiput. Head neck: Injected conjunctivae, greenish ocular discharge, ulcerative oral lesions. Cardiovascular: Regular rhythm. Rapid rate. murmurs. Pulmonary: Clear auscultation bilaterally. Abdomen: Normoactive bowel sounds. Soft, nontender, nondistended. Extremities: edema. Skin: Diffuse erythema pustules face. Patulous pustules chest, back, proximal upper extremities. GU: genital lesions. LABORATORY DATA: Hematocrit 34.1, WBC 10.3, platelet count 291,000, differential 87 neutrophils, 0 bands; sodium 133, potassium 3.8, chloride 93, CO2 21, BUN 17, creatinine 0.9, glucose 121; ALT 39, AST 42, LDH 434, amylase 63, albumin 3.4, total bilirubin 0.3; urinalysis positive ketones, negative nitrites; urine culture pending; blood cultures times two pending; conjunctival culture pending. HOSPITAL COURSE: Given patient's severe exfoliative skin involvement rapid progression extensive involvement body, admitted Medical Intensive Care Unit close monitoring. started prophylactic Oxacillin cover skin flora, Dermatology consulted along Neurology Ophthalmology ophthalmic involvement. patient's course Intensive Care Unit uneventful, discharged floor close monitoring included q.1 hour Pred Forte application eye close consultation Ophthalmology. regard skin lesions, continued exfoliate next couple days, skin care included frequent Vaseline hydrated petroleum application decrease insensible losses. patient's intake output closely monitored replaced appropriately; however, intensive nursing care requirement made difficult patient receive adequate floor, therefore, transferred Medical Intensive Care Unit frequent ophthalmic applications skin care. MICU, patient continued meticulous skin care eye care. skin lesions continued desquamate exfoliate natural progression disease. began involvement genital area continued desquamation exfoliative lesions. course Intensive Care Unit within next 8-10 days slow gradual improvement dermatologic ophthalmologic standpoint. cardiovascular standpoint, sinus tachycardia felt secondary [Doctor Last Name ]-[Location (un) ] syndrome leading dehydration insensible fluid losses. Intensive Care Unit, also found mildly hypoxic likely secondary atelectasis patient's immobility. Lower extremity Dopplers also done, deep venous thromboses found. Infectious Disease standpoint, patient started intravenous Oxacillin empirically. Blood cultures 5th growth times two; however, one bottle PICC line grew gram-positive cocci [7-27]. started course Vancomycin. Subsequently organism found CNS Corynebacterium, Vancomycin discontinued prior transfer floor [8-5]. patient's course floor uncomplicated continued improvement. Dermatology: patient, indicated, improved dramatically presentation time discharge. exfoliative lesions healed course admission. skin care requirements decreased Petroleum jelly twice day time discharge. able take oral foot without problems. Ophthalmology: patient's eye care requirement improved markedly. able open eyes use vision without significant problems time discharge. Pred Forte discontinued day discharge, follow-up Ophthalmology couple days discharge. Fluid, electrolytes, nutrition: admission patient begun TPN nutritional support. patient improved medical perspective, TPN weaned, time discharge, patient taking adequate p.o. supplementation Boost. Infectious Disease: time admission, started empiric antibiotics placed contact precautions secondary extensive skin lesions; however, patient improved throughout course admission, contact precautions discontinued, patient discharged home services. Cardiology/Pulmonology: patient tachycardiac throughout admission attributed fluid losses secondary [Doctor Last Name ]-[Location (un) ] syndrome; however, given patient's immobility throughout course admission, CT angiogram performed evaluate possible pulmonary embolism, none found. Neurology: patient history cystic tumor status post resection [Month (only) 205] year started prophylactic Dilantin leading presumed [Doctor Last Name ]-[Location (un) ] syndrome. time admission, patient's Dilantin discontinued, anticonvulsants started, given patient's risk seizures several weeks surgery unlikely. decision made support neurosurgeon, Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 1338]. Five days discharge, patient syncopal event bathroom showering help nursing aide. likely etiology orthostatic hypotension fluid losses; however, given patient's neurologic history, Neurology consulted evaluate possible seizure. Neurology's recommendations obtain repeat CT scan unchanged previous showing right frontal lobe extra-axial hypodensity stable. also recommended repeat MR imaging unremarkable except stable extra-axial lesion noted CT scan. Neurology therefore agrees primary team syncopal event likely secondary vasovagal reaction. follow-up MR scan would recommended gadolinium evaluate presence residual tumor. done outpatient Dr. [Last Name (STitle) 1338]. Rehabilitation: patient throughout admission worked physical therapy people continued improve regard range motion strength upper lower extremities, time discharge, ambulating throughout [Doctor Last Name ] around hospital without problems. therefore discharged home without need Physical Therapy Services. time discharge, patient markedly improved initial presentation discharged home nursing assistance. DISCHARGE STATUS: Markedly improved. DISCHARGE DIAGNOSIS: 1. [Doctor Last Name ]-[Location (un) ] syndrome secondary Dilantin. 2. Status post craniotomy [2109-7-1], cystic cranial lesion, likely dysembryoplastic angioneural epithelial lesion features consistent oligodendroglioma. DISCHARGE MEDICATIONS: Polysporin ophthalmology O.U. q.i.d., hydrated Petroleum needed, Lipitor 10 mg p.o. q.d., Nystatin, Boost t.i.d. FOLLOW-UP: 1. Ophthalmology [2109-8-20], 12:45 p.m. 2. Primary care physician two weeks. 3. Dermatology needed. DISCHARGE NOTE: PLEASE NOTE PATIENT ALLERGIC DILANTIN TEGRETOL GIVEN [Doctor Last Name ]-[Location (un) ] SECONDARY DILANTIN. patient recommended wear alert bracelet indicates reaction. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern4) 40425] MEDQUIST36 D: [2109-9-3] 12:59 T: [2109-9-3] 12:58 JOB#: [Job Number 99931] [Name6 (MD) ] [Name8 (MD) ], M.D.(cclist)	[ "2720" ]
Admission Date: [2144-3-7] Discharge Date: [2144-3-16] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2145] Chief Complaint: transfer OSH [State 108] R hip fx. Major Surgical Invasive Procedure: R hip ORIF History Present Illness: HPI: [Age 90 ]F hx dementia, CAD, CHF EF 40%, chronic afib, lives 24 hour caretaker. brought OSH neck pain inability hold head well confusion, found transverse C2 dens fracture, immobilized [Location (un) 5622] collar. Pt fell 3 weeks prior admission, home aide stated injuries fall. Noted CHF exacerbation --> resolving diuresis reportedly stable [3-20] liters NC (uses O2 home). In-house OSH, fall unfortunately suffered right intertrochanteric fracture. Pt family [Hospital1 1559] pt med flighted [State 108] [Hospital1 18]. Family connection [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Reportedly, C2 fracture stable surgeons wanted immobilize hip could addressed. . Pt cardiology consult [State 108], CHF exacerbation BNP 15,000. Toprol XL increased 37.5 50 mg PO qd plan increase 100 mg po QD. started digoixin. lasix increased. . note, transfer paperwork notes pt seen PCP [Name9 (PRE) 108] exertional CP SOB relieved NTG [Month (only) 1096] [2143]. time Imdur increased 30 60 mg PO qd. . hospitalization increasingly agitated started Risperdal, recently d/c'd became increasingly confused. . Labs OSH: [3-6]: INR 1.1, Na 146, K 3.8, Cl 106, HCO3 33, BUN 29, Cr 1.0, Ca 8.7 Dig 1.0, [3-2] Blood Cx: NGTD . Studies: [3-2] EKG: afib 98bpm RAD, LVH, QTc 526, bad baseline [3-4] CT Head mod-severe atrophy, bleed [3-5] R hip/pelvis, comminuted fx R hip [3-5] CT cervical spine: transverse fx base dens. displacement. Transverse lucency spinous process C3 (chronic) Transverse lucency spinous process C3 (chronic). [3-3] CXR: Mild CHF, patchy infiltrate base right lung, small bilateral pleural effusions. . Past Medical History: PMH: CHF EF 40%, [2-20] echo: inf hypokinesis CAD, hx MI, s/p PCI LAD, LCx RCA stents [2136] [Hospital1 ] afib hypercholesterolemia COPD HTN severe ([2-20] echo 59 mmHg peak gradient, valve area 0.6 cmsq) mod-severe MR mild MS [First Name (Titles) ] [Last Name (Titles) ] Dementia (Mild Alzheimer's vs vascular) per transfer paperwork, however pt's family states hospitalization pt living independently live help. Hiatal hernia s/p repair hx GIB AVM associated elevated INR [4-18] s/p ccy s/p TAH macular degeneration kyphoscoliosis DJD/OA Social History: Social Hx: widowed, 4 children. Lived independently 24 hour aides. EtOH tob. Transferring physician: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 24606] [Last Name (NamePattern1) 79] cell [Telephone/Fax (1) 65356] (is on-call weekend) [Hospital 32303] Medical Center [Hospital 65357], [State 108] [Telephone/Fax (1) 65358]. [Name (NI) ] son: [Name (NI) ] [Name (NI) 122] [Telephone/Fax (1) 65359] HCP, lives [Name (NI) 108] coming [3-7]. Pts daughter ([Name (NI) 19948] [Last Name (NamePattern1) ]) lives [Name (NI) 1559] phone number [Telephone/Fax (1) 65360]. . [Hospital1 1559] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] ([Hospital1 ]) [Hospital1 1559] Cardiologist: Dr. [Last Name (STitle) 65361] ([Hospital1 ]) Physical Exam: PE: VS: 98.6 HR 64 R 20 BP 88/54 95%2L Gen: NAD, laying bed Aspen collar HEENT: slight droop L eyelid, PERRL, MMM, O/P clear Neck: Aspen collar Chest: crackles bases, clear apices CV: [Last Name (un) 3526] [Last Name (un) 3526] rate rhythm, 3/6 SEM RUSB rad carotids, 3/6 systolic murmur apex Abd: soft, NT, ND +BS Ext: pain palpation R hip, lim ROM. edema, 2+ DP pulses bilaterally Neuro: alert, oriented person only, moves 4. Brief Hospital Course: [Age 90 ] yo F h/o dementia, CAD, diastolic CHF (EF 55%), severe AS, chronic afib, transferred OSH R hip fracture possible C2 fracture operative management hip. stable floor initial arrival. Given CHF AS, high risk surgical candidate, family decided go ahead operation. Postoperatively MICU briefly hypotension extubated without difficulty, weaned pressors rehydration transferred back floor. Perioperatively, developed UTI LIJ clot, treated. Postoperatively, also developed delirium, less verbal previously. failed speech swallow evaluation, medical team optomistic would improve. meantime, multiple attempts NGT placement unsuccessful. floor, [3-14]-30, patient showed signs inability clear secretions. [3-15], episode hypoxia. CXR time revealed fluid overload, seemed improve lasix. Overnight night, 1/2 blood culture bottles positive S.aureus Vancomycin started. [3-16], continued poorly, hypoxic. CXR time revealed dry lungs, likely aspiriation PNA LUL. Despite aggressive suctioning broadening antibiotic coverage, Mrs. [Known lastname 65362] continued deteriorate ultimately died approx 4:25 PM [3-16]. . # COde - DNR/DNI verified son HCP. . # Communication: son [Name (NI) ] [Name (NI) 122] [Telephone/Fax (1) 65359] (HCP; daughter ([Name (NI) 19948] [Name (NI) ] [Telephone/Fax (1) 65360]). [Hospital1 1559] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] ([Hospital1 ]); [Hospital1 1559] Cardiologist: Dr. [Last Name (STitle) 65361] ([Hospital1 ]). Previously [Hospital 32303] Medical Center [Last Name (LF) 65357], [First Name3 (LF) 108] [Telephone/Fax (1) 65358]. . Medications Admission: Meds transfer: Lipitor 40 mg PO qd Digoxin 0.125 mg qD Lasix 80 mg IV BID Atrovent neb QID Imdur 30 mg PO qd Levalbuterol neb QID Losartan 12.5 mg PO BID Toprol XL 50 mg PO qd coumadin 2 mg PO alternating 3 mg PO qd (held) Tylenol prn Discharge Disposition: Expired Discharge Diagnosis: Hip fracture s/p ORIF LIJ clot UTI Aspiration PNA Perioperative delirium Discharge Condition: Death Discharge Instructions: None. Followup Instructions: None. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "5990", "2851", "4019", "2720" ]
Admission Date: [2179-3-5] Discharge Date: [2179-3-24] Date Birth: [2105-3-13] Sex: F Service: MEDICINE Allergies: Benzodiazepines Attending:[First Name3 (LF) 3984] Chief Complaint: shortness breath, red hands feet Major Surgical Invasive Procedure: endotracheal intubation, mechanical ventilation, right IJ central line placed, tracheostomy tube placed History Present Illness: Ms. [Known lastname 94714] 73yo woman h/o ALS presents 3 weeks redness hands feet well recent difficulty breathing. patient complained dyspnea husband noted tachypnea respiratory distress per husband went doctor today, noted "not breathing well" sent ER hypoxic 80s, responding well O2 NC. found ABG 7.19/126/525/51 started Bipap. tolerate non-invasive mask ventilation despite sedateion (versed 2mg, fentanyl 100mg). experienced reduction blood pressure 66/30, subsequently intubated. Per husband, patient ALS three years. performs ADLs trouble speech well keeping mouth closed baseline. respiratory complaints. previously lost 40 pounds last year given Gtube since gained back 14 pounds. [Name (NI) 1094] husband states prior last 3 weeks USOH, denies new symptoms including cough, sputum, sick contacts. entirely NPO year. CXR ER showed acute CP process UA negative signs infection. Per pt's husband never sort conversation regarding code status. patinet try bipap past unable tolerate it, outpatient neurologist never mentioned intubation tracheostomy. Mr. [Known lastname 94714] states new thoughts he's entirely certain wife would want point. transferred [Hospital Unit Name 153], started AC 450x16, 100% FiO2, PEEP 5. ABG setting 7.40/57/426/37 FiO2 turned 50%. Past Medical History: - ALS diagnosed 3y ago - Gtube tube feeds, difficulty speech - hypercholesterolemia -?depression Social History: lives home husband, three children two live west coast one lives [Location ]. never used tobacco, drink alcohol, drugs. Works writer. baseline performs ADLs, writes, uses internet chat grandchildren. Family History: father MI age 52, mother deceased age [Age 90 ] Physical Exam: 96.7, 78, 112/64, 16, 100% AC settings Gen: sedated, unresponsive, intubated HEENT: PERRL, NCAT Cor: s1s2, RRR, r/g/m Pulm: CTAB Abd: soft, NT, ND, +BS, Gtube c/d/i Ext; c/c/e, bilateral toes skin changes c/w venous stasis, bilateral fingers erythematous dry excoriated skin Neuro: babinski upgoing bilaterally, myoclonus BLE, hyperreflexic B patellar, biceps Pertinent Results: arrival Na 126, CK 273-->115, MB 14-->10, trop <0.01--> <0.01, bicarb 40, UA negative [2179-3-23] 02:44AM BLOOD WBC-10.0 RBC-2.88* Hgb-9.4* Hct-27.6* MCV-96 MCH-32.7* MCHC-34.1 RDW-13.5 Plt Ct-316 [2179-3-23] 02:44AM BLOOD Neuts-78.7* Bands-0 Lymphs-15.8* Monos-3.6 Eos-1.6 Baso-0.3 [2179-3-22] 04:15AM BLOOD PT-11.7 PTT-22.6 INR(PT)-1.0 [2179-3-23] 02:44AM BLOOD Glucose-127* UreaN-24* Creat-1.3* Na-145 K-4.5 Cl-107 HCO3-31 AnGap-12 [2179-3-19] 05:54AM BLOOD ALT-49* AST-44* LD(LDH)-267* AlkPhos-142* Amylase-41 TotBili-0.3 [2179-3-19] 05:54AM BLOOD Lipase-30 [2179-3-5] 02:50PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-<0.01 [2179-3-5] 10:15PM BLOOD CK-MB-10 MB Indx-8.7* cTropnT-0.01 [2179-3-23] 02:44AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4 [2179-3-19] 05:54AM BLOOD TSH-3.0 [2179-3-18] 11:55AM BLOOD Cortsol-23.9* [2179-3-18] 12:51PM BLOOD Cortsol-43.3* [2179-3-18] 01:48PM BLOOD Cortsol-51.1* [2179-3-22] 04:11PM BLOOD Type-ART pO2-136* pCO2-50* pH-7.45 calHCO3-36* Base XS-9 [2179-3-22] 04:11PM BLOOD Lactate-1.2 . [2179-3-12] 10:57 pm BLOOD CULTURE LT PIV. FINAL REPORT [2179-3-18] AEROBIC BOTTLE (Final [2179-3-15]): REPORTED PHONE [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2179-3-13] @ 2:35 PM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST reported also RESISTANT penicillins, cephalosporins, carbacephems, carbapenems, beta-lactamase inhibitor combinations. Rifampin used alone therapy. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 TETRACYCLINE---------- <=1 VANCOMYCIN------------ <=1 ANAEROBIC BOTTLE (Final [2179-3-18]): GROWTH. . [2179-3-13] 12:20 SPUTUM Source: Endotracheal. FINAL REPORT [2179-3-15] GRAM STAIN (Final [2179-3-13]): >25 PMNs <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS CLUSTERS. RESPIRATORY CULTURE (Final [2179-3-15]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST reported also RESISTANT penicillins, cephalosporins, carbacephems, carbapenems, beta-lactamase inhibitor combinations Rifampin used alone therapy. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 TETRACYCLINE---------- <=1 VANCOMYCIN------------ <=1 . [3-15] ECHO: 1.The left atrium normal size. 2.There mild symmetric left ventricular hypertrophy. left ventricular cavity size normal. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). 3. Right ventricular chamber size normal. 4.The aortic valve leaflets (3) appear structurally normal good leaflet excursion. aortic regurgitation seen. 5.The mitral valve leaflets mildly thickened. mitral regurgitation seen. 6.There pericardial effusion. . [2179-3-5] EKG: Sinus rhythm. Slight ST segment elevation leads II, III aVF may represent active inferior ischemic process. Followup clinical correlation suggested. previous tracing available comparison . [2179-3-12] EKG: Atrial fibrillation rapid ventricular response, rate 160. Non-specific repolarization changes. Compared previous tracing [2179-3-5] normal sinus rhythm abbreviated P-R interval given way atrial fibrillation rapid ventricular response . [3-21] CXR: continues dense opacification retrocardiac region consistent left lower lobe collapse small left effusion. patchy areas increased opacity right lower lung left mid lung may represent early infiltrate volume loss. significant change compared film two days ago. right subclavian line unchanged. . [2179-3-22] Renal US: Mildly echogenic otherwise normal-appearing kidneys may secondary medical renal disease. 1.1 x 0.9 cm echogenic focus left kidney may represent cholesterol deposit versus nonobstructing kidney stone. Brief Hospital Course: # hypercarbic resp failure: felt likely ALS induced muscular weakness combined possible acute PNA given LLL consolidation CXR. intubated repiratory failure, treated possible pneumonia. able tolerate weaning ventilator, therefore required tracheostomy longer term ventilator support. awaiting trach placement, Ms. [Known lastname 94714] also developed ventilator associated pneumonia. grew MRSA sputum blood, treated course vancomycin. Zosyn added 5 days vancomycin repeated L lung collapse thick mucous plugging, wanted cover pneumonia well. Subsequent surveillance cultures clean. Zosyn later switched Cefepime [1-7] worsening renal failure attributed Zosyn. completed 8 day course antibiotics. tracheostomy went well, started in/exsufflator well aid clearing secretions/mucous prevent recurrent lung colapse. . # fib: Ms. [Known lastname 94714] several episodes atrial fibrillation RVR, setting L lung collapse. initially started beta blocker good response. multiple episodes started amiodarone anticoagulation heparin. cases converted sinus rhythm own. Shortly starting heparin, episode guaiac positive stool, small amount melena. heparin stopped, restarted remained sinus rhythm, concern risk GI bleeding higher risk stroke. PEG lavaged, OB negative. also need colonoscopy outpatient evaluate cause melena. subtle ST changes inital EKG, ruled MI enzymes. . # hypotension: Ms [Known lastname 94714] hypotensive intial presentation, responding well fluid boluses. cortisol stimulation test normal response. became clear responds sedation benzodiazepines prolonged hypotension (as well increased delerium agitation), therefore stopped, put allergy list. cessation benzodiazepines, blood pressure much stable, require bolusing. never required pressors. . # ALS: felt likely progression ALS, diaphragmatic weakness CO2 retention. respiratory mechanics repeatedly asessed, showed would able come vent. Therefore trach placed thoracic surgery (IP unable place due anatomy). . # hyponatremia: Mrs [Known lastname 94714] hyponatremic admission. Tis resolved hydration, indicating likely hypovolemic total body sodium depleted. problems duration stay. . #Diarrhea: New [2179-3-24]/ Slight increase WBC 15. Afebrile. abdominal pain. course antibiotics vent associated PNA. antibiotics stopped today. ALso tube feeds. C. Diff possibility given recent abx may also related tube feeds. C.Diff pending. point reasonable follow fever curve stool output. C.Diff lab followed up. [Month (only) 116] consider empiric treatment c. diff flagyl febrile diarrhea persists. . #Hypernatremia - Likely releated low volume. increase free water tube feeds 100cc q4hr 150cc q4h. chenistry panel checked [2179-3-26] make sure Na remains stable. . # conjunctivitis: Ms. [Known lastname 94714] bilateral conjunctivitis admission. resolved 7 day course erythromycin eye cream. . # skin changes: Ms [Known lastname 94715] intitial presenting chief complaint erythema hands feet. Dermatology consulted, said likely erythromyalgia. treatment sarna lotion aspirin, improvement occur less month. treated sarna ASA throughout stay. Additionally burns inside thighs hot tea spill home prior admission. Per dermatology recs, areas treated antibiotic cream xeroform dressings, healed cleanly without infection. . # FEN: Ms. [Known lastname 94714] PEG admission able take PO intake time secondary progression ALS. continued NPO, tubefeeds per nutrition. monitored & repleted electrolytes lytes. kept euvolemic. #Renal Failure: Pt's Creatinine increased admission 0.7 1.3. BUN remained around 20 .Urine lytes consistent ATN>Reanla failure attributed ATN d/2 Zosyn.Although chenged Cefepime, improvement. Renal US showed obstruction. Pt's creatinitne remained near 1.3.Plan keep pt hydrated , avoid nephrotoxins follow creatinine outpatient. . # PPX: Ms. [Known lastname 94714] treated SC heparin, protonix, bowel regimen. constipation, bowel regimen increased good results. . # access: maintained PIVs throughout hospitalization. Shortly discharge PICC line placed losing peripheral access. . # code status: Per discussion Ms [Known lastname 94714] husband full code throughout stay. Medications Admission: Elavil (stopped weeks ago) Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: [12-7] PO BID (2 times day). 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times day). 6. Bisacodyl 10 mg Suppository Sig: [12-7] Suppositorys Rectal DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times day). 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. Disp:60 Tablet(s) Refills:0 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 6 hours) needed. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Amiotrophic Lateral Sclerosis Hypercarbic Respiratory Failure Atrial Fibrillation Recurrent Pneumonia-Ventilator Associated Pneumonia Renal Failure Discharge Condition: good , afebrile , cough , fever, tracheostomy good condition. Discharge Instructions: Please continue using exsuflator needed.PLease come back ED new episode worsening cough, fever productive sputum. . Pleae take medications prescribed. . noted diarrhea morning prior discharge, please call [Hospital1 18] check results c. diff stool culture [2179-3-25], consider c. diff study diarrhea continues. Followup Instructions: PCP: [Name10 (NameIs) ],[First Name3 (LF) 2946] S. [Telephone/Fax (1) 2936] . Recent onset diarrhea. Please call [Hospital1 18] microbiology lab ([Telephone/Fax (1) 94716] follow results c. diff toxin assay. . Please check cbc chem 7 [2179-3-26]. New onset hypernatremia [2179-3-24]. Free water increased tube feeds [2179-3-24]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2179-3-24]	[ "486", "2724", "2859" ]
Admission Date: [2196-9-27] Discharge Date: [2196-10-17] Date Birth: [2151-3-3] Sex: Service: SURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: ESLD Major Surgical Invasive Procedure: [2196-9-27] liver transplant History Present Illness: 45M history EtOH cirrhosis, MELD 28 Child class C cirrhosis recently admitted [Hospital1 18] last month fevers, anemia, ascites ARF. brief, recent hospital course, treated C.perfringens bacteremia treated Zosyn. Paracentesis performed reveal spontaneous peritonitis. EGD evaluation showed Grade varices. renal failure issues responded octreotide midodrine. resumed diuretic last Cr normalized baseline (1.0). admitted preparation liver transplant. Denies change health since previous admission. Afebrile still rather lethargic home. Tolerating regular diet. Normal bowel habits, described often loose. abdominal tenderness tender paracentesis site. food since midnight. Past Medical History: EtOH cirrhosis EtOH Abuse Gout s/p appendectomy several yrs ago h/o HTN normotensive meds [2196-9-27] liver transplant Social History: lives wife sons 10 14 yo. Works energy broker. Denies drug tobacco use. Quit drinking 6 weeks ago Family History: Adopted family hx unknown Physical Exam: 98.9 91 128/77 18 98RA Gen: AAOX3, NAD HEENT: scleral icterus, MMM, EOMi, NCAT Skin: Jaundice Cardio: RRR Pulm: CTAB Abd: Soft, obese, umbilical hernia noted, tender paracentesis site, distended/ascites, spider angiomas Ext: 3+ pitting edema b/l LE Neuro: focal deficits CXR: EKG: Sinus rhythm. Non-specific anterior ST-T wave changes. Delayed precordial R wave transition Labs: 135 97 11 estGFR: >75 ---\|----\|----< 104 4.3 28 1.0 Ca: 9.7 Mg: 1.7 P: 3.4 ALT: 16 AST: 48 AP: 92 Tbili: 18.6 Alb: 4.0 7.7> 8.2 <149 25.1 PT: 27.2 PTT: 55.8 INR: 2.7 Fibrinogen: 59 recent workup: Liver/RUQ US ([2196-8-26]): 1) Cirrhosis ascites. 2) New, partially occlusive main portal vein thrombosis extending left portal vein. Please note, study limited right portal vein, splenic vein, portal venous confluence well visualized. 3) Distended gallbladder without signs acute cholecystitis. Findings may due fasting state EGD ([2196-8-26]): Varices lower third esophagus gastroesophageal junction, Linear non bleeding erosion 35 cm. Erythema, abnormal vascularity mosaic appearance whole stomach compatible portal hypertensive gastropathy. Otherwise normal EGD second part duodenum TTE [8-30]: EF> 60% Pertinent Results: [2196-10-17] 04:53AM BLOOD WBC-9.5 RBC-2.90* Hgb-8.7* Hct-27.0* MCV-93 MCH-29.9 MCHC-32.1 RDW-16.4* Plt Ct-334 [2196-10-13] 09:32AM BLOOD PT-11.7 PTT-23.6 INR(PT)-1.0 [2196-9-30] 02:52AM BLOOD Fibrino-180 [2196-9-27] 05:00AM BLOOD Glucose-104 UreaN-11 Creat-1.0 Na-135 K-4.3 Cl-97 HCO3-28 AnGap-14 [2196-9-28] 04:16PM BLOOD Glucose-114* UreaN-30* Creat-2.3* Na-142 K-4.6 Cl-104 HCO3-28 AnGap-15 [2196-9-30] 10:50PM BLOOD Glucose-122* UreaN-70* Creat-4.6* Na-137 K-5.8* Cl-97 HCO3-26 AnGap-20 [2196-10-2] 06:10AM BLOOD Glucose-137* UreaN-87* Creat-5.2* Na-135 K-5.2* Cl-93* HCO3-26 AnGap-21* [2196-10-7] 05:07AM BLOOD Glucose-147* UreaN-94* Creat-3.6* Na-130* K-4.2 Cl-94* HCO3-24 AnGap-16 [2196-10-17] 04:53AM BLOOD Glucose-93 UreaN-69* Creat-2.0* Na-132* K-5.2* Cl-100 HCO3-21* AnGap-16 [2196-9-27] 05:00AM BLOOD ALT-16 AST-48* AlkPhos-92 TotBili-18.6* [2196-10-17] 04:53AM BLOOD ALT-33 AST-31 AlkPhos-276* TotBili-1.6* [2196-10-17] 04:53AM BLOOD Calcium-8.7 Phos-4.7* Mg-1.5* Brief Hospital Course: [2196-9-27], underwent deceased donor liver transplant. Surgeon Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Two 19-French [Doctor Last Name 406] drains placed posterior liver behind portal structures. Please refer operative note complete details. Aggressive blood product resuscitation anesthesiology staff well administration protamine performed. Induction immunosuppression started intraop (solumedrol). Postop, transferred SICU management received blood products maintain hemodynamic stability per protocol. LFTs initially increased expected. Hepatic duplex revealed inadequate flow demonstrated within right posterior portal vein could technical nature versus small amount thrombus. Patency appropriate direction flow within hepatic arteries, hepatic veins, left main portal veins seen. Splenomegaly noted. repeat study [10-1] revealed patency appropriate direction flow within hepatic portal venous systems. High flow velocities main portal vein, aliasing expected region anastomosis noted. notation fatty infiltration liver. LFTs trended (ast 580, alt 530, alk phos 130, t.bili 6.6). JP outputs remained high averaging 900-1100ml per day. LFTs started trend postop day 4 5. JP output appeared foamy. [10-4], ERCP performed noting common bile duct mild narrowing bile duct anastomosis, minimal associated proximal ductal dilatation. filling defects CBD intrahepatic ducts. evidence bile leakage. plastic biliary stent placed. Post procedure, amylase lipase wnl. JP drain outputs continued high averaging much 2200ml/day. IV fluid replacements albumin administered per output. lateral JP removed [10-5]. medial JP continued drain much 1800ml per day. IV lasix given anasarca several days. Teds stockings applied improvement edema. Weight decreased 90.4 Kg [10-16] 117.4 [9-26]. medial JP removed [9-14]. site remained dry suturing. note, alk phos continued rise 518. Repeat ERCP done [10-13]. obstruction biliary stent. stent exchanged. alk phos continued increase. [10-14], liver biopsy performed noting rejection. Marked bile ductular proliferation associated neutrophilic inflammation, focal ductal dilation, marked cholestasis, bile plug formation portal tract edema; Rare foci mild portal mononuclear inflammation scattered eosinophils; endothelialitis diagnostic involvement acute cellular rejection identified. steatosis viral inclusion seen. Rare peri-venular lipofuscin-laden macrophages, suggestive resolving reperfusion injury. ERCP, LFTS trended (ast 31, alt 33, alk phos 276, t.bili 1.6). postop pyloric feeding tube replaced [10-6] removed ERCP. experienced ATN likely intraop hemodynamics. Creatine 1.0 [9-27]. started rise postop high 5.2 postop day 5. gradually, creatinine improved with. Creatinine decreaed 1.8 [10-13], started trend 2.0 likely Prograf trough elevated. Levels increased 14.1 [10-16]. Prograf dose adjusted 0.5mg [Hospital1 ] [10-16] 1mg [Hospital1 ]. Immunusuppression consisted cellcept 1gram [Hospital1 ] well tolerated. Solumedrol tapered per transplant protocol prednisone. Prograf started postop day 1 adjusted per trough levels. Diet slowly advanced, poorly tolerated patient appetite. postpyloric feeding tube placed tube feedings started (novasource renal). Oral intake slowly increased, insufficient support caloric needs. [10-10] Dermatology biopsied L thumb chronic non-healing, bleeding punctate lesion (started [4-21]). Biopsy report noted many features suggestive lichen simplex chronicus/prurigo nodularis, mild atypia present favored reactive context. central ulceration could secondary excoriation; alternatively, may represent channel transepidermal elimination foreign body setting perforating disorder (although clinical history suggestive latter). underlying pyogenic granuloma cannot entirely excluded basis sample; clinical suspicion persists, deeper sampling may helpful definitive diagnostic evaluation. bleeding stopped site remained clean dry. PT worked extensively hospital course deconditioning. experience fall onto right hip(slipped transferring bed). pain hip flexion pain exam greater trochanter. Xrays hip negative. required contact guard rolling walker time discharge, ready discharge home. Rehab recommended [Hospital1 ] accepted him. transferred [10-17]. Medications Admission: Folic Acid 1, Thiamine HCl 100, Ursodiol 300''', Ranitidine HCl 150'', lactulose, Furosemide 20, Spironolactone 100, Zofran 4, Maalox, Rifaximin 200''' Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times day). 4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY DAY (Every Day). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) needed pain. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times day) needed itching. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Please fax prograf trough levels [Telephone/Fax (1) 697]. Call [Telephone/Fax (1) 673] dose adjustments, attn [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ], RN coordinator. 13. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): follow taper schedule per [Hospital1 18] Transplant . Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: etoh cirrhosis s/p liver transplant [2196-9-27] bile duct narrowing, s/p stent malnutrition Left thumb bleeding s/p biopsy: pyogenic granuloma ATN, resolving Discharge Condition: good Discharge Instructions: Please call [Hospital1 18] Transplant Office [Telephone/Fax (1) 673] fever, chills, nausea, vomiting, inability take medications, jaundice, abdominal distension, increased abdominal pain, edema, dizziness, incision redness/bleeding/drainage concerns Continue tube feedings ordered (Novasource renal 45cc/hr continuously via feeding tube) Labs every Monday Thursday 9am cbc, chem 10, LFTs, albumin trough prograf level results fax'd [Hospital1 18] Transplant Office [Telephone/Fax (1) 697] attention [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ], RN coordinator [Telephone/Fax (1) 10575] [Month (only) 116] shower, heavy lifting/straining Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2196-10-20] 3:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2196-10-27] 11:30 Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2196-10-27] 1:20 Completed by:[2196-10-17]	[ "4280" ]
Admission Date: [2150-12-24] Discharge Date: [2150-12-26] Date Birth: [2092-10-10] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Dyspnea Major Surgical Invasive Procedure: None History Present Illness: 58f breast cancer, HTN, CHF, PAF s/p PVI presents shortness breath, increasing past day. notes symptoms became gradually, increasing dyspnea exertion productive cough developed palpitations, increased dyspnea related this. pulse fast irregular. came emergency department found rapid atrial fibrillation; chest x-ray revealed pneumonia. recieved levofloxacin IV diltiazem ED admitted. Past Medical History: 1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, amiodarone. 2. CHF diastolic EF 62% MRI [3-6] 3. Breast cancer Stage II status post right mastectomy status post six months tamoxifen therapy, s/p XRT 4. Hypertension. 5. Hyperlipidemia. Social History: Patient married lives husband. denied smoking alcohol use. Family History: NC Physical Exam: 99.4, bp 134/86, hr 122, rr 18, spo2 96% 2L nc gen- pleasant f, looks age, mild distress, non-toxic heent- anicteric, op clear mmm neck- jvd/lad/thyromegaly cv- tachy, irreg irreg, m/r/g pul- moves air well, slight bibasilar rales r>l abd- soft, nt, nd, nabs extrm- cyanosis/edema, warm/dry nails- clubbing, pitting/color changes/indentations neuro- a&ox3, focal cn/motor deficits Pertinent Results: [2150-12-24] 10:00PM BLOOD WBC-6.5 RBC-4.33 Hgb-13.0 Hct-36.7 MCV-85# MCH-29.9 MCHC-35.4# RDW-14.7 Plt Ct-150 [2150-12-26] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-25 AnGap-13 [2150-12-24] 10:00PM BLOOD CK(CPK)-54 TotBili-0.6 [2150-12-24] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2150-12-26] 06:00AM BLOOD CK(CPK)-81 [2150-12-26] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2150-12-25] 06:40AM BLOOD ALT-31 AST-18 AlkPhos-76 TotBili-0.5 [2150-12-25] 06:40AM BLOOD TSH-4.6 Brief Hospital Course: 58f breast cancer, htn, chf, paf s/p pvi admitted pneumonia afib rapid ventricular response . Afib -- Mrs. [Known lastname ] maintained amiodarone home sinus rhythm. felt pneumonia likely culprit exacerbation back fibrillation. seen EP staff felt would well loading dose amiodarone 400mg twice daily three days; would return usual dose 200mg daily. begun good response. Sinus rhythm quickly re-instated. symptoms dyspnea palpitations seems improved reversion sinus. discharged one day loading-dose amidodarone left sinus rhythm, rates generally 70's. . Pneumonia -- Although clinically mild, felt sufficient cause loss sinus rhythm. O2 requirement treated course levofloxacin. time discharged, afebrile decreased cough sputum production. Micro data unrevealing. Medications Admission: Pantoprazole 40mg daily Amiodarone 200mg daily Metoprolol 25mf twice daily Warfarin 2mg mon-fri 1mg sat-sun ASA 325mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times day). 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 4 days. Disp:4 Tablet(s) Refills:0 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO SAT-SUN (). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MON-FRI (). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times day) 1 days: Take 2 pills twice day Saturday Sunday, return 200mg day. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Atrial fibrillation rapid ventricular response Pneumonia Secondary: 1. PAF s/p pulm vv isolation, w/ recurrence s/p radiation, amiodarone. 2. CHF, one episode post cardioversion, diastolic EF 55% 2/04 3. Breast cancer Stage II status post right mastectomy status post six months tamoxifen therapy, s/p XRT 4. Hypertension 5. Hyperlipidemia Discharge Condition: Good, sinus rhythm, improved symptoms Discharge Instructions: admitted pneumonia rapid heart rate; heart rate controlled temporarily increased dose amiodarone, given antibiotics pneumonia. . Call PCP return ED fevers/chills, chest pain, shortness breath, lightheadedness, loss conciousness, concerning symptoms. . Take 400mg amiodarone twice day Saturday Sunday, return usual dose 200mg day Monday. Followup Instructions: Please see primary care doctor next 1-2 weeks; call [Telephone/Fax (1) 2740] make appointment. . Provider: [Last Name (NamePattern4) 105871] NP/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2151-3-4] 8:00 . Provider: [Name10 (NameIs) 326] [Name11 (NameIs) ] DX RM2 RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2151-3-9] 11:00 . Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2151-3-19] 3:15	[ "486", "4019", "2724", "2859" ]
Admission Date: [2115-1-11] Discharge Date: [2115-1-19] Date Birth: [2033-12-10] Sex: Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 7881] Chief Complaint: chest pain Major Surgical Invasive Procedure: Cardiac Catheterization History Present Illness: 81 year old man CAD s/p CABG [2103] LIMA LAD, SVG PDA, SVG OM, HTN, IDDM, PVD s/p bilateral LE bypass, CRI, admitted [Hospital3 417] Hospital [1-7] shortness breath chest pain x one week. Initially thought rest angina. Ruled MI, EKG changes. Transferred cath. holding area pt chest pain, EKG changes. Underwent difficult catheterization today(received large amount radiation)which demonstrated severe native three vessel disease. left main heavily calcified 80% distal stenosis. left anterior descending received blood LIMA graft. left circumflex demonstrated 90% ostial lesion. RCA diffusely diseased. LIMA-LAD graft patent. SVG-OM patent; SVG-RPDA patent 85% mid RCA lesion. attempt PCI today due excessive radiation dose dye dose. Pt scheduled planned PCI SVG-rPDA possible LMCA intervention Monday. Past Medical History: HTN IDDM CAD s/p CABG [2103] LIMA LAD, SVG PDA, SVG OM ([2103]) PVD s/p bilateral LE bypass COPD carotid disease CRI BPH s/p TURP nephrolithiasis history thrombocytopenia Social History: Social history significant 50 pack year smoking history; quit '[03], ETOh drug use. Lives home wife, independent ADLs. Family History: NC Physical Exam: GEN: elderly male, NAD HEENT: NC/AT, EOMI, PERRL, O/P clear, MMM Neck: JVP+9, supple CV: RRR, m/r/g Lungs: CTA bilaterally Abd: Obese, soft, NT, ND Ext: WWP, edema Neuro: A&O x3 Pertinent Results: [2115-1-11] 09:15PM GLUCOSE-208* UREA N-45* CREAT-1.9* SODIUM-136 POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13 [2115-1-11] 09:15PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-2.2 [2115-1-11] 09:15PM WBC-4.1 RBC-3.07* HGB-10.1* HCT-29.7* MCV-97 MCH-32.9# MCHC-34.0 RDW-15.7 [2115-1-11] 09:15PM PLT COUNT-96* [2115-1-11] 06:16PM GLUCOSE-369* UREA N-45* CREAT-1.8* SODIUM-134 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14 [2115-1-11] 06:16PM estGFR-Using C.CATH [1-11] COMMENTS: 1. Selective cornary angiography right dominant system revealed diffuse three vessel coronary artery disease. LMCA unable engaged selectively despite using 4 french JL4, JL4.5, JL5. five french JL5, JL4.5, AL1, AL2, AL3 also unsucessful. LMCA heavily calcified ostial plaque. 80% distal LMCA lesion involved origins LAD, ramus, [Month/Day (4) ]. LAD functional ostial stenosis (extended distal LMCA); signficiant proximal stenosis; minimal flow mid LAD. Overall, LAD able well visualized difficulty engaging LMCA. [Month/Day (4) ] 90% stenosis origin extended distal LMCA. AV groove [Month/Day (4) ] supplied diffusely disease OM1 (up 70% stenosis) LPL. ramus well seen ostial 80% stenosis. heavily calcified plaque aorta origin RCA. RCA heavy calcification proximally 70% 90% stenoses. mid vessel 50% stenosis. distal RCA tortuous vessel supplied long lower acute marginal lateral branches supplied inferior septum. native AV groove RCA heavily calcified subtotally occluded take-off large lower AM. 2. Venous conduit angiography revealed SVG OM (engaged 5 french AL2) patent thoughout touched onto lower pole OM communicate native AV groove [Name (NI) ]. SVG-rPDA (engaged 5 french MPA) ostial 30% mid 85% stenosis; graft retrogradely filled severely diffusely diseased distal AV groove RCA gave septal collaterals LAD. 3. Nonselective arterial conduit angiography revealed patent LIMA 30% ostial stenosis touches small calibur, heavily calcifed LAD (not well imaged). 4. Left subclavian angiography revealed heavily calcifed vessel proximal 50% stenosis. left subclavian stenosis prevented advancement 4 french [Female First Name (un) 899] catheter despite use angled glide wire, slip catheter, Amplatz stiff wire. 4 french Berenstein ultimately advance subclavian distal LIMA angled glide wire. 5. Left ventriculography perfomed secondary renal insufficency. 6. Limited hemodynamics demonstrated systemic systolic hypertension central aortic pressure 167/68 (systolic/diastolic mmHg). severe diastolic dysfunction LVEDP 32 mmHg. gradient across aortic valve pullback. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. . [1-14] Cardiac cath: 1. Planned intervention 90% body SVG-PDA lesion direct stenting Vision 3.5x18mm stent. 2. Limited hemodynamics BP 142/59 HR 55 significant ventricular ectopy. 3. Access via 6F long sheath RFA. FINAL DIAGNOSIS: 1. Succesful direct stenting SVG-PDA graft bare metal stent. Brief Hospital Course: . #. CAD: patient presented OSH [1-7] shortness breath chest pain. transferred [Hospital1 18] cardiac cathterization. diagnostic procedure [2115-1-11] complicated requiring signficant amount dye radiation, therefore, intervention planned another day. demonstrated severe native 3vd, patent LIMA-LAD, SVG-OM, 90% [Date Range ] ostial lesion, diffusely diseased RCA 85% lesion patent SVG-RPDA. received Reopro post cathterization developed hematoma requiring pressure dressing. patient developed refractory chest pain without ECG changes intervention could performed, transferred CCU monitoring management. CCU, given Argatroban ACS (reported concern re: HIT). cardiac cathterization [2115-1-14] intervention stenting SVG-RCA. sheath pulled Argatroban patient developed significant hematoma requiring 2 units pRBC transfusion. next day, patient developed stuttering chest pain plans made take back cath lab possible intervention left main RCA. transitioned nitro gtt isosorbide chest pain. started argatroban prior procedure. underwent third catheterization [1-17] stenting L. Subclavian. subsequently remained chest pain free. continued aspirin, Plavix, statin, Toprol. events occured, chest pain resolved sent home medications. . #. Systolic Heart Failure: echo performed showed EF 60%. Patient continued Lasix beta blocker increased. . #. Rhythm: Patient normal sinus rhythm hospital stay, however CCU episodes bradycardia beta blocker held. subsequently resumed prior discharge. . #. Diabetes-Patient placed insulin sliding scale placed back home glyburide prior discharge. . #CRI-Baseline 2.2 OSH. initially increased first catheterization subsequently improved post-cath hydration IVF. creatinine monitored remained stable throughout rest hospitalization. medications renally dosed received pre- post-cath hydration procedures. . #Hematuria-Pt gross blood foley thought related traumatic insertion. foley subsequently flushed clots. evidence hematuria intervention taken. . #BPH-Patient continued home hytrin . #Thrombocytopenia-Patient known chronic thrombocytopenia. unclear baseline is, OSH platelets low 100s. HIT Ab sent negative. Heparin held throughout stay platelets remained stable 80s low 100s. intervention taken. . #Chronic Anemia-Pt Procrit q week (tues). received 2 units prbcs CCU hematoma HCt subsequently remained stable. receive Procrit hospitalization resumed per regular schedule upon discharge. . #Sciatica-Patient continued home Neurontin. Medications Admission: ASA 325mg daily Nexium 40mg daily Toprol XL 25mg daily MVI Neurontin 300nmg daily Hytrin 2mg PO QHS Lasix 40mg daily Glyburide 5mg daily Iron 325mg daily Procrot q week (tues) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO day. 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO day. 11. Procrit Injection 12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes three times needed pain: Tkae every 5 minutes three doses; working call doctor go ER. Discharge Disposition: Extended Care Facility: Baypointe - [Hospital1 1474] Discharge Diagnosis: Primary CAD s/p 3 PCIs . Secondary HTN IDDM COPD PVD CRI BPH Thrombocytopenia Discharge Condition: Improved Discharge Instructions: admitted hospital chest pain. underwent 3 cardiac catheterizations stents placed blocked vessels heart. complication one procedures bruising swelling groin resolved. . changes made medications. started Lipitor, Plavix. medications kept same. . chest pain, shortness breath, nausea,vomiting, palpitations, lightheadednes, bleeding groin, concerning symptoms, please call doctor return ER. . Please follow Followup Instructions: Please follow cardiologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 2 weeks. Please call make appt PCP [Last Name (NamePattern4) ] [4-8] weeks.	[ "5849", "4019", "4280" ]
Admission Date: [2179-9-22] Discharge Date: [2179-10-14] Date Birth: [2125-3-18] Sex: Service: CARDIOTHORACIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: VF arrest Major Surgical Invasive Procedure: [2179-10-7]: MV repair/MAZE/ left atrial appendage resection [2179-10-13]: AICD placement History Present Illness: 54 year old male known pmh presented s/p ventricular fibrillation arrest [2179-9-22]. Red Sox game sister walking car stopped smoke cigarette collapsed. passing physician initiated CPR within 3-5 minutes per sister's report. found ventricular fibrillation shocked 5 times, given 3mg epinephrine, 2mg magnesium torsades rhythm. eventually spontaneous return circulation breathing. intubated field route [Hospital1 18]. transferred ED CCU put arctic sun protocol. unresponsive sedated eventually extubated [9-25] agitated uncooperative. history ETOH heavy smoker. Cardiac cath [2179-9-29] revealed coronary disease 3+ mitral regurgitation. evaluated mitral valve repair. Past Medical History: unknown, gone doctor least 20 years. Social History: Lives with: sisters Occupation: works [Last Name (un) ] chemical pipefitting Tobacco:1.5 ppd many years, current ETOH: beers per night, several weekends Family History: family history early MI, arrhythmia, cardiomyopathies, sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:108 Resp: 20 O2 sat: B/P Right: 93/81 Left: Height: 6'3" Weight: 60.7 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] NGT place tube feeds. Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur III/VI holo diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: A+Ox3 unable swallow still impulsive restrained. Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: Pertinent Results: [2179-10-12] 04:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.5* Hct-31.2* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.4 Plt Ct-242 [2179-10-11] 06:05AM BLOOD WBC-15.0* RBC-3.33* Hgb-10.6* Hct-32.4* MCV-97 MCH-32.0 MCHC-32.9 RDW-14.4 Plt Ct-213 [2179-10-12] 04:40AM BLOOD PT-14.0* INR(PT)-1.2* [2179-10-11] 06:05AM BLOOD PT-12.9 INR(PT)-1.1 [2179-10-12] 04:40AM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-137 K-3.6 Cl-99 HCO3-31 AnGap-11 [2179-10-11] 06:05AM BLOOD Glucose-91 UreaN-14 Creat-0.6 Na-134 K-3.7 Cl-96 HCO3-31 AnGap-11 [2179-10-12] 04:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.5* Hct-31.2* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.4 Plt Ct-242 [2179-10-13] 04:40AM BLOOD PT-16.6* INR(PT)-1.5* [2179-10-13] 04:40AM BLOOD UreaN-14 Creat-0.7 Na-133 K-4.2 Cl-100 [2179-10-14] 04:20AM BLOOD WBC-14.4* RBC-3.32* Hgb-10.4* Hct-31.5* MCV-95 MCH-31.4 MCHC-33.1 RDW-14.5 Plt Ct-307 [2179-10-14] 04:20AM BLOOD UreaN-16 Creat-0.7 Na-132* K-4.2 Cl-94* CT HEAD W/O CONTRAST Study Date [2179-9-22] FINDINGS: hemorrhage, edema, mass effect, evidence acute vascular territorial infarction. shift normally midline structures [Doctor Last Name 352]-white matter differentiation well preserved. size configuration ventricles appears normal. Osseous structures intact. opacification bilateral maxillary sinuses. Ethmoid air cells demonstrate mucosal thickening. trace fluid within mastoid air cells bilaterally. left occipital posterior scalp hematoma. IMPRESSION: 1. acute intracranial process. 2. Left occipital scalp hematoma, without fracture. Intra-op TEE [2179-10-7] Pre-CPB: Mild spontaneous echo contrast seen body left atrium. Overall left ventricular systolic function mildly depressed (LVEF= 40 - 45 %). mild global free wall hypokinesis. 1+ AI. simple atheroma descending thoracic aorta. mitral valve shows characteristic myxomatous deformity. moderate/severe posterior leaflet mitral valve prolapse. Moderate severe (3+) mitral regurgitation seen. pericardial effusion. Post-CPB: patient infusons Epi NTG, AV-Paced. mitral ring good position leak MR. Residual area 2.8 cm2. Biventricular systolic fxn mildly improved. TR remains 1+, AI remains 1+. Aorta intact. Brief Hospital Course: 54 year old male known past medical history admitted VF arrest Red Sox game. underwent CPR field along defibrillation transition atrial fibrillation. admitted [Hospital1 18] CCU initiated Arctic Sun cooling protocol cardiac arrest. Initial echocardiogram showed severe mitral valve prolapse regurgitation flail mitral valve, likely precipitant VF arrest. patient extubated successfully approximately 48 hours rewarming. Upon admission, started empiric antibiotic therapy possible aspiration pneumonia cefepime, vancomycin metronidazole. taken operating [2179-10-7] underwent left sided maze procedure Mitral Valve repair (see operative note full details). Overall patient tolerated procedure well post-operatively transferred CVICU stable condition recovery invasive monitoring. Vancomycin used surgical antibiotic prophylaxis, given length preoperative stay. POD 1 found patient extubated, alert oriented breathing comfortably. patient neurologically intact hemodynamically stable, weaned inotropic vasopressor support. Amiodarone started atrial fibrillation. Beta blocker initiated patient gently diuresed toward preoperative weight. Intra-operatively, patient found osteoporotic appearing sternum. [Month/Day/Year 6091] consulted recommended outpatient follow following recovery cardiac surgery. patient continued exhibit dysphagia, dobhoff tube placed feeding purposes. Coumadin started atrial fibrillation. patient transferred telemetry floor recovery. Chest tubes pacing wires discontinued without complication. patient evaluated physical therapy service assistance strength mobility. dual chamber ACID placed [2179-10-13] without complication. interrogated [10-14] follow appointment device clinic arranged. repeat video swallow study cleared nectar thick ground diet tube feeds cycled. Dobhoff tube removed day discharge patient instructed speech swallow team aspiration precautions. follow outpatient video swallow study (scheduled) diet advancement. started ACE-I EF 35% blood pressure tolerated. INR 2.3 day discharge given 1 mg Coumadin plans INR drawn [10-15] results called [Hospital3 271] [Telephone/Fax (1) 2173] Coumadin dosing instructions. INR goal [2-3] atrial fibrillation. time discharge POD 7 patient ambulating freely, wound healing well staples place pain controlled oral analgesics tolerating ground diet. patient discharged home services good condition appropriate follow instructions follow appointments arranged. Medications Admission: None Discharge Medications: 1. furosemide 20 mg Tablet [Month/Day (3) ]: One (1) Tablet PO day 7 days. Disp:7 Tablet(s) Refills:0 2. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal [Month/Day (3) ]: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 3. aspirin 81 mg Tablet, Delayed Release (E.C.) [Month/Day (3) ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 4. nicotine 14 mg/24 hr Patch 24 hr [Month/Day (3) ]: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:1 5. thiamine HCl 100 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. folic acid 1 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable [Month/Day (3) ]: One (1) Tablet, Chewable PO BID (2 times day). 8. cholecalciferol (vitamin D3) 400 unit Tablet [Month/Day (3) ]: 2.5 Tablets PO DAILY (Daily). 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 10. metoprolol tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 11. amiodarone 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times day) 30 days: Take x 30 days per cardilogist instructions. Disp:60 Tablet(s) Refills:0 12. warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO (Once) 1 doses: Take instructed cardiologist INR goal 2.0-3.0. Disp:60 Tablet(s) Refills:0 13. clindamycin HCl 300 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO twice day 2 days. Disp:4 Capsule(s) Refills:0 14. lisinopril 2.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:1 Discharge Disposition: Home Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Mitral regurgitation/ Atrial fibrillation Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed Incisions: Sternal - healing well, erythema drainage Leg 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments Provider: [Name10 (NameIs) 6091] [First Name11 (Name Pattern1) 3972] [Last Name (NamePattern4) 3973], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2179-11-29] 2:30 Provider: [Name10 (NameIs) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2179-10-29] 9:10 Surgeon: Dr [Last Name (STitle) ] [2179-10-27] 1:00 PM Cardiologist: [Last Name (LF) 171], [First Name3 (LF) ] [2179-11-8] 1:20 PM EP Device Clinic 1 week [Telephone/Fax (1) 62] [10-19] 11:30 Primary Care Dr. [Last Name (STitle) ] [4-5] weeks Video swallow follow 2 weeks - scheduled Labs: PT/INR Coumadin ?????? indication Atrial Fibrillation Goal INR 2/0-3.0 First draw [2179-10-15] Results Dr[Name (NI) 87655] office phone [Telephone/Fax (1) 1989] NP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 87656] Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Completed by:[2179-10-14]	[ "5849", "4019" ]
Admission Date: [2111-9-29] Discharge Date: [2111-10-5] Date Birth: [2050-1-9] Sex: Service: CARDIOTHORACIC Allergies: Ampicillin / Amoxicillin / Ativan Attending:[First Name3 (LF) 165] Chief Complaint: fatigue Major Surgical Invasive Procedure: OP CABGx2(LIMA-LAD,SVG-OM)[10-1] History Present Illness: 61 yo 2 month decline energy malaise walking home, unable sleep tripped/lost balance fell bath tub developed SOB. OSH, found R ptx rib fx. also found pulmonary edema elevated trops.Had known CAD, uncerwent repeat cath showed significant CAD. Tansferred [Hospital1 18] eval. Past Medical History: Acute Chronic systolic heart failure DM HTN [Hospital1 18048] ESRD - HD (MWF) - last dialysis [11-8]; [11-11] Thrombectomy L arm fistula [12-22] Hypercholesterolemia GIB [10-20] prepyloric area EGD (? [12-19] NSAIDS) Gastritis [12-22] (EGD) Anemia Hip surgery [6-21] - coumadin Prostate adenocarcinoma Chronic low back pain Social History: Occasional EtOH, tobacco, drugs Family History: Mother: [Name (NI) 18048] Physical Exam: Obese NAD Neuro A&O, forgetful train though, wanders, grip strenth L [3-21], R [2-19] PERRL CV RRR 2/6 SEM Resp crackles thoughout Right, Left clear GI obese, soft/NT Right groin macerated/fungal infection Pertinent Results: [2111-10-4] 08:20AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.4* Hct-24.9* MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4* Plt Ct-130* [2111-10-3] 08:35AM BLOOD WBC-7.9 RBC-3.03* Hgb-9.4* Hct-27.5* MCV-91 MCH-31.1 MCHC-34.2 RDW-16.9* Plt Ct-127* [2111-10-4] 08:20AM BLOOD Plt Ct-130* [2111-10-3] 08:35AM BLOOD Plt Ct-127* [2111-10-1] 01:33PM BLOOD PT-19.9* PTT-39.1* INR(PT)-1.9* [2111-10-4] 08:20AM BLOOD Glucose-155* UreaN-38* Creat-6.8# Na-129 K-4.4 Cl-89* HCO3-30 AnGap-14 [2111-10-3] 08:35AM BLOOD Glucose-123* UreaN-22* Creat-5.2* Na-135 K-4.2 Cl-92* HCO3-31 AnGap-16 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 21518] (Complete) Done [2111-10-1] 10:54:10 FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2050-1-9] Age (years): 61 Hgt (in): 70 BP (mm Hg): 137/74 Wgt (lb): 235 HR (bpm): 68 BSA (m2): 2.24 m2 Indication: Intraoperative TEE CABG ICD-9 Codes: 410.91, 440.0 Test Information Date/Time: [2111-10-1] 10:54 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5740], MD Doppler: Full Doppler color Doppler Test Location: Anesthesia West cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aorta - Descending Thoracic: 2.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 7 mm Hg Aortic Valve - LVOT pk vel: 0.[Age 90 ] m/sec Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: 2.0 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. spontaneous echo contrast thrombus LA/LAA RA/RAA. four pulmonary veins identified enter left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. ASD 2D color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Moderate regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size free wall motion. AORTA: Normal aortic diameter sinus level. Focal calcifications aortic root. Mildly dilated ascending aorta. Simple atheroma aortic arch. Mildly dilated descending aorta. Simple atheroma descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve well seen. PERICARDIUM: pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. TEE related complications. patient appears sinus rhythm. Results personally reviewed MD caring patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, = Akinetic, = Dyskinetic Conclusions PRE-revascularization: 1. left atrium mildly dilated. atrial septal defect seen 2D color Doppler. 2. mild symmetric left ventricular hypertrophy. left ventricular cavity mildly dilated. moderate severe regional left ventricular systolic dysfunction inferior, septal anterior walls. Overall left ventricular systolic function mildly depressed (LVEF= 40 %). 3. Right ventricular chamber size free wall motion normal. 4. simple atheroma aortic arch. descending thoracic aorta mildly dilated. simple atheroma descending thoracic aorta. 5. three aortic valve leaflets. aortic valve leaflets moderately thickened focal calcification left coronary cusp causing aorto sclerosis. aortic valve stenosis. Trace aortic regurgitation seen. 6. mitral valve leaflets mildly thickened. Trivial mitral regurgitation seen. 7. pericardial effusion. Post revascularization: Pt phenylephrine infusion intrinsic sinus rhythm: 1. Normal Rv function. LVEF 40% 2. new regional wall motion abnormalites, valves listed pre-revascularization. 3. Thoracic aortic contour intact CHEST (PORTABLE AP) [2111-10-2] 4:28 PM CHEST (PORTABLE AP) Reason: r/o ptx [Hospital 93] MEDICAL CONDITION: 61 year old man s/p cabg ct removal REASON EXAMINATION: r/o ptx HISTORY: Status post CABG chest tube removal; assess pneumothorax. FINDINGS: comparison study [9-21], endotracheal tube, Swan-Ganz catheter, nasogastric tube removed. Left chest tube also removed evidence pneumothorax. probably residual atelectatic change left base well right upper zone, decreasing. Brief Hospital Course: admitted cardiac surgery. seen renal continue HD. taken operating room [10-1] underwent OPCABG x 2. transferred ICU critical stable condition. given vancomycin perioperative prophylaxis house preoperatively. extubated morning POD #1. continued HD postop. transferred floor POD #1. started renagel per renal. well postoperatively ready discharge rehab POD #4. Medications Admission: crestor 40', colace 150", zoloft 100', lisinopril 40', norvasc 10', asprin 81', thiamin 100', plavix 75', protonix 40', toprol xl 200', ambien 10', folate 1", sensipar 180', lovaza 1"" Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES DAY MEALS). 5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cinacalcet 30 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. Discharge Disposition: Extended Care Facility: [Hospital 38] Rehab [Location (un) 1110] Discharge Diagnosis: CAD s/p CABG Acute Chronic systolic heart failure ESRD HD(L AV fist), CAD s/p MI, HTN, ^lipids, DM2 , s/p L THR, prostate CA s/p cryo/lupron, h/o gastric ulcer Discharge Condition: Good. Discharge Instructions: Call fever, redness drainage incision weight gain 2 pounds one day five one week. Shower, baths, lotions,creams powders incisions. lifting 10 pounds driving follow surgeon. Followup Instructions: Dr. [Last Name (STitle) 20764] 2 weeks Dr. [First Name (STitle) ] 4 weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2111-10-5]	[ "4280", "2724" ]
Admission Date: [2173-10-1] Discharge Date: [2173-10-20] Date Birth: [2133-4-7] Sex: Service: PLASTIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 26411] Chief Complaint: perineal infection Major Surgical Invasive Procedure: [2173-10-1] Radical debridement scrotum, perineum abdomen. History Present Illness: HPI: pt 40yM history diabetes transferred [Hospital 8641] Hospital Mediflight presented scrotal pain swelling 2 days incision drainage small scrotal abscess found exam c/w Fournier's Gangrene subcutaneous gas CT. pt reports waited ED [Location (un) 8641] 3 hours early afternoon erythema scrotum swelling progressed lower abdominal region. transfer [Hospital1 18], noted afebrile course hour became diaphoretic ill appearing. pt denies SOB< CP, neurological sx, urinary sx, GI sx. PMH: DM, HTN, chronic back pain PSH: Vasectomy Med: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000' All: NKDA Soc: Live [Last Name (un) 53428], NH. Wife [Doctor First Name 803] reached [Telephone/Fax (1) 79837] Labs: CH 7 129 94 25 306 AGap=18 3.3 20 1.3 CBC- 11.5 / 34.1 / 142 PT: 15.1 PTT: 26.2 INR: 1.3 OSH CT Abd: Scrotal air tracking anteriorly posteriorly additional gas buttock PE: VS: 100.4 96 100/56 21 94 Diaphoretic RRR CTAB Abdomen soft, NT, NT, erythema tracking right inguinal crease, within marker, crepitus palpable left inguinal crease Phallus circumcised mild, ecchymosis base Scrotum size grapefruit, ecchymotic, crepitus present, focal area dark purple break skin midline, testes non-palpable Perineum indurated without crepitus, bleeding perineal wound Anus without crepitus, Past Medical History: DM, HTN, chronic back pain Vasectomy Social History: Live [Last Name (un) 53428], NH. Wife [Doctor First Name 803] reached [Telephone/Fax (1) 79837] Physical Exam: Day Discharge Gen: acute distress Cards: RRR Pulm: Lungs clear Auscultation Abdomen: soft non-tender Wound: well-approximated, healing, drains maintaining suction clear serosanguinous drainage. Skin graft 100% take. Mild maceration/irritation skin medial bilateral thighs secondary moisture friction. Pertinent Results: [2173-9-30] 10:30PM NEUTS-89.1* LYMPHS-7.5* MONOS-2.9 EOS-0.5 BASOS-0.1 [2173-9-30] 10:30PM WBC-11.5* RBC-5.24 HGB-11.8* HCT-34.1* MCV-65* MCH-22.5* MCHC-34.6 RDW-13.9 [2173-10-1] 02:30AM HGB-10.4* calcHCT-31 [2173-10-1] 04:25AM WBC-12.5* RBC-4.21* HGB-9.6* HCT-29.5* MCV-70* MCH-22.8* MCHC-32.5 RDW-13.5 [2173-10-1] 11:18AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2173-10-1] 12:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Pt life-flighted [Hospital1 18]. Pt diagnosed Fournier's gangrene, taken emergently Urology ER radical perineal debridement. Please see operative note dictated separately. Pt transferred SICU still intubated IV insulin, IV antibiotics (Vanc, Zosyn, Clinda), hourly wound checks, pressor/ventilator support. POD2 Pt taken back re-debridement wound margins Gen [Doctor First Name ] Urology. SICU, pt relatively uneventful course. see notes below. [9-30]: transfer [Hospital 8641] Hospital, s/p incision drainage perineal abscess 2 days ago followed increasing pain redness fever, evaluated today found clinical radiological findings c/w Fournier's gangrene. Transferred [Hospital1 18] surgical evaluation treatment. States fevers chills. [10-1]: added clindamycin antibiotic coverage, minimally marching erythema, added propofol sedation. wound swab day taken + enterococcus. cultures neg. [10-2]: back debridement right thigh. weaned levo using fluid [10-3]: bronchoscopy performed [10-4]:NGT placement--TF started. low grade temp. flexiseal placed [10-5]:started insulin gtt refractory blood sugars setting chronic wound care, lasix gtt albumin [10-6]: weaned versed/fent, weaned vent, started diamox, started precedex wean extubation [10-7]: Extubated. Aggitated, responding haldol prn [10-9]: acute events, changed po meds, po lasix, increased RISS, PCA oral pain control, d/c'ed insulin gtt Pt transferred Urology floor service stable condition. Wound care, glycemic control, continued antibiotics provided. Pt taken Plastic Surgery local flap closure debrided area VAC placement bolster skin graft testicles. patient well floor. kept bed rest POD1-5 strict restrictions abducting legs. addition, continued IV antibiotics per ID recommendations. POD 5 VAC dressing taken skin graft 100% take. day discharge POD 7, patient well. Afebrile vital signs stable, pain well controlled oral regimen, cleared home Physical therapy, drain outputs decreased appropriately. Per ID recs, patient require additional IV antibiotic therapy. Medications Admission: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000' Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q12H (every 12 hours). Disp:24 Tablet Sustained Release(s) Refills:0 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once day (at bedtime)). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) needed pain. Disp:50 Tablet(s) Refills:0 7. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 12. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice day 10 days. Disp:20 Capsule(s) Refills:0 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous twice day: take breakfast Bedtime. Take [2-28] dose eating. . Disp:2 vials Refills:2 14. Diabetic supplies 1/2 cc 30gauge insulin syringes prn Glucometer testing strips PRN Discharge Disposition: Home Service Facility: ROCKINHAM VNA Discharge Diagnosis: Fournier's Gangrene Discharge Condition: hemodynamically stable, tolerating oral intake, ambulating, voiding without difficulty, pain controlled oral regimen Discharge Instructions: Return ER if: * vomiting cannot keep fluids medications. * shaking chills, fever greater 101.5 (F) degrees 38 (C) degrees, increased redness, swelling discharge incision, chest pain, shortness breath, anything else troubling you. * serious change symptoms, new symptoms concern you. * Please resume regular home medications take new meds ordered. * drive operate heavy machinery taking narcotic pain medication. may constipation taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); continue drinking fluids, may take stool softeners, eat foods high fiber. Meds Take medications ordered. Drains VNA help dressing changes wound checks well drain care. important keep good records drain output bring records return clinic. Followup Instructions: Please call Dr.[Name (NI) 29526] office ([Telephone/Fax (1) 26412] followup appointment 1 week. Please call Dr.[Name (NI) 11306] office ([Telephone/Fax (1) 8791] followup appointment. F/u PCP regarding insulin regimen blood glucose control Completed by:[2173-10-20]	[ "4019" ]
Admission Date: [2171-8-17] Discharge Date: [2171-8-21] Date Birth: [2134-4-7] Sex: F Service: Transplant Surgery Service CHIEF COMPLAINT: Fever, chills, nausea, vomiting, dysuria. HISTORY PRESENT ILLNESS: patient 37-year-old female postop pancreas transplant [2171-8-7], living unrelated renal transplant [2170-8-14]. presents 36 hours history increasing fever chills, nausea vomiting. patient reported shakes home. Temperature 101.7. patient noted foul smelling urine. Upon admission patient agitated tachycardic heart rate 120. vital signs normal. PAST MEDICAL HISTORY: IDDM, status post living unrelated renal transplant [2170-8-14]. MEDICATIONS HOME: 1. Prograf 3 mg PO b.i.d. 2. CellCept 1 gram b.i.d. 3. Valcyte 900 mg day. 4. Prednisone 4 mg daily. 5. Bactrim single strength 1 daily. 6. Nystatin 5 ml PO QID. 7. Protonix 40 mg PO b.i.d. 8. Os-Cal b.i.d 9. Fosamax q week. PHYSICAL EXAMINATION: Temperature 102.8, heart rate 108, blood pressure 136/80, respiratory rate 18, 98% room air. patient alert oriented, agitated. Cranial nerves II XII intact. Pupils equal, round reactive light. Lungs clear bilaterally. Incision clean dry intact. Abdomen tender approximately around incision. Positive bowel sounds. Legs - edema. HISTORY BRIEF HOSPITAL COURSE: patient 37-year- old female presenting severe nausea vomiting, fever foul smelling urine. lady's likely diagnosis pyelonephritis versus UTI superimposed anxiety attacks. patient admitted transplant unit started IV fluid empiric Zosyn. Chest x-ray done demonstrated pleural effusions. infiltrates. Lung fields clear. nasogastric tube inserted. Correct position noted stomach. patient underwent supine film abdomen. Gas noted loops colon. patient underwent CT abdomen pelvis without contrast. demonstrated evidence abscess benign appearing fluid collection along course right iliac vessels, likely representing lymphocele. patient admitted SICU monitoring. White blood cell count admission 21.1, hematocrit 31.5, creatinine 1.2, day 1 0.9, amylase 22, lipase 14, glucose 91. EKG revealed sinus tachycardia. ST-T wave changes. Urine positive nitrates. WBC 30, large amount blood. previously stated patient started Zosyn. Urine blood cultures sent. Blood cultures subsequently negative. Urine culture demonstrated E. coli 100,000 colonies, resistant ampicillin Bactrim, sensitive cephalosporins, imipenem, Levo, meropenem. hospital 2, patient temperature 104.5. given Tylenol aggressive IV hydration. continued Zosyn Linezolid. White blood cell count increased 30.3. complained back pain well. Temperature defervesced. patient transferred medical- surgical unit hospital day 3. Temperature 99. Abdomen soft. slowly advanced house diet. IV therapy decreased. Urine output approximately 500 cc per day clear yellow urine. patient continued feel anxious. Glucoses normal. Foley catheter removed. patient followed nephrology throughout hospital course. Prograf level 7.1. Prograf adjusted accordingly. Creatinine 1.2, BUN 13, amylase 23, lipase 17 glucose 112. note, patient complained right hip pain hospital day 3. medicated IV Dilaudid fair relief. patient felt muscle spasm right hip, erythematous swelling. Physical therapy consulted. Localized inflammation noted. Concern trochanteric bursitis. patient independent mobility. independent transfer, stairs, hallway ambulation. Outpatient PCA recommended. patient's antibiotic switched ceftriaxone IV. patient discharged home hospital day 5. given prescription Keflex 1 week Macrobid. Urine output approximately 1.5 liters per day. Glucose remained within normal range. afebrile. DISCHARGE MEDICATIONS: 1. Prednisone 4 mg PO daily. 2. Valcyte 900 mg PO daily. 3. Nystatin 5 mg PO QID. 4. Bactrim single strength 1 PO daily. 5. CellCept 1 gram PO b.i.d. 6. Prograf 3 mg PO b.i.d. 7. Protonix 40 mg PO daily. 8. Aspirin 81 mg, enteric coated, one PO daily. 9. Hydrocodone/ acetaminophen 5/325 mg 1 tab PO p.r.n. q4 hours. 10. Keflex 500 mg PO QID x 10 days. 11. Macrodantin 100 mg cap 1 PO daily. DISCHARGE DIAGNOSES: 1. Status post pancreas transplant [2171-8-7]. 2. Status post living unrelated renal transplant [2170-8-14]. 3. Urinary tract infection. 4. Urosepsis. patient instructed follow Dr. [First Name (STitle) ] [Name (STitle) ] [2171-8-26]. also follow [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] social service well Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [2171-9-6]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD, PhD [Numeric Identifier 8353] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2171-11-12] 16:00:13 T: [2171-11-13] 02:12:59 Job#: [Job Number 41013] cc:[Name8 (MD) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD	[ "5990" ]
Admission Date: [2136-7-14] Discharge Date: [2136-7-17] Date Birth: [2059-8-27] Sex: F Service: SURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: 76F s/p fall Major Surgical Invasive Procedure: none History Present Illness: 76F s/p fall; patient originally seen outside hospital, transferred [Hospital1 18]. Past Medical History: hypertension bilateral total hip replacements Social History: EtOH use Family History: unknown Physical Exam: AXO person, place, event CN 2-12 intact RRR CTA b/l +bs, nt, nd, soft pelvic instability gross abn extremities rectal guaiac neg, mass LE palp distal pulses Pertinent Results: [2136-7-14] 02:00AM BLOOD ASA-NEG Ethanol-46* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2136-7-14] 07:50AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.1* [2136-7-15] 02:40AM BLOOD Calcium-7.3* Phos-2.1* Mg-3.3* [2136-7-14] 02:00AM BLOOD CK-MB-3 cTropnT-<0.01 [2136-7-14] 07:50AM BLOOD CK-MB-3 cTropnT-<0.01 [2136-7-14] 02:00AM BLOOD CK(CPK)-104 [2136-7-14] 07:50AM BLOOD CK(CPK)-106 [2136-7-14] 02:00AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-142 K-3.5 Cl-102 HCO3-21* AnGap-23* [2136-7-14] 07:50AM BLOOD Glucose-188* UreaN-7 Creat-0.7 Na-142 K-3.2* Cl-102 HCO3-21* AnGap-22* [2136-7-15] 02:40AM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-142 K-4.1 Cl-111* HCO3-21* AnGap-14 [2136-7-14] 02:00AM BLOOD PT-12.6 PTT-21.0* INR(PT)-1.1 [2136-7-14] 02:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ [2136-7-14] 02:00AM BLOOD Neuts-90.6* Bands-0 Lymphs-5.6* Monos-3.6 Eos-0.1 Baso-0 [2136-7-14] 02:00AM BLOOD WBC-13.7* RBC-3.81* Hgb-14.5 Hct-42.1 MCV-110* MCH-38.1* MCHC-34.5 RDW-15.9* Plt Ct-407 [2136-7-15] 02:40AM BLOOD WBC-5.4 RBC-2.92* Hgb-11.2* Hct-32.3* MCV-111* MCH-38.5* MCHC-34.8 RDW-16.1* Plt Ct-284 [2136-7-16] 09:05AM BLOOD Hct-37.8 [2136-7-14] 01:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2136-7-14] 01:20AM URINE Hours-RANDOM [2136-7-14] 01:20AM URINE RBC-[2-12]* WBC-[2-12] Bacteri-MOD Yeast-NONE Epi-1 [2136-7-14] 01:20AM URINE Blood-LGE Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2136-7-14] 01:20AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.005 AP CXR: 1. compression deformities several lower thoracic vertebral bodies, uncertain chronicity. 2. widening ascending aortic contour, may represent aneurysmal dilatation. AP Pelvis: bilat THR, Fx CT c-spine: Marked osteopenia degenerative changes seen, without definite fracture subluxation identified CT head: Bilateral areas intraparenchymal (hemorrhagic contusions) subarachnoid hemorrhage EKG: Sinus tachycardia. Left ventricular hypertrophy. Diffuse ST-T wave changes may secondary left ventricular hypertrophy. previous tracing available comparison Brief Hospital Course: Patient admitted intraparenchymal subarachnoid hemorrhages, poorl controlled hypertension. hospital course (by system): Neuro: Patient 2 CT head done, without interval change, mental status improved hospital course. Patient also develop focal neurologic deficits. treated dilantin seizure prophylaxis 7-day course, also received valium DT prophylaxis. CV: Patient treated metoprolol lisinopril hypertension, BP maintained 160 SBP throughout hospital course. Patient also EKG showed sinus tachycardia [7-14]; HR decreased within normal limits discharge. Resp: Patient treated incentive spirometry hospital course, respiratory status good throughout hospital stay. GI: Patient received colace hospital course, tolerated regular diet throughout; also received protonix GI prophylaxis. GU: patient foley place hospital course; d/c'd without incident, patient able urinate own. FEN: Patient received thiamine, folate mulivitamin admission EtOH use risk Wernicke-Korsakoff syndrome. Heme: issues ID: issues Medications Admission: norvasc zestril Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times day: hold SBP <100 HR <55. 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed. 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times day) 4 days. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: 1) subarachnoid hemorrhage 2) frontal intraparenchymal hemorrhage 3) hypertension (poorly controlled admission) Discharge Condition: stable Discharge Instructions: suffered intraparenchymal hemorrhage subarachnoid hemorrhage following fall. return headache, nausea/vomiting, difficulty breathing, chest pain, decreased sensation motor function, symptoms concerning you. Followup Instructions: follow-up Trauma Clinic 2 weeks ([Telephone/Fax (1) 6439]) follow-up neurosurgery 2 weeks ([Telephone/Fax (1) 1669]) follow-up PCP regarding BP control [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2136-7-17*]	[ "4019" ]
Admission Date: [2115-1-20] Discharge Date: [2115-1-31] Service: NEUROLOGY Allergies: Percocet / Penicillins / Atropine / Keflex / Bactrim / Inderal / Levaquin / Reglan / Ciprofloxacin Hcl / Doxycycline / Azithromycin Attending:[Doctor Last Name 15044] Chief Complaint: prolonged R sided shaking Major Surgical Invasive Procedure: intubation History Present Illness: Briefly, pt [Age 90 ] year old woman PMH notable breast CT [2081] (s/p R mastectomy), pancreatic CA [2094] (s/p whipple's), colon CA d/c'ed [1-2], s/p total colectomy, transferred ICU presenting partial status epilepticus. According daughter, recent colectomy complications post-operative ileus, overall decreased po's weight loss. nursing home relatively stable day prior admission tired taking po's. night nursing aid noted L face, arm, leg twitching, unclear true LOC associated it. twitching began around midnight continued morning brought [Hospital1 18] evaluation. ED noted talking coherently twitching, O2 sats low 90's 2L NC. given total 4 mg ativan 1 gm dilantin bolus stopped shaking, however became sedated required intubation. admitted ICU management. Past Medical History: 1. pancreatic cancer status post Whipple procedure [2094] 2. Multiple duodenal strictures ulcers 3. Adhesions status post lysis radiation pancreas. 4. Status post transverse colectomy radiation-induced injury colon. 5. Status post appendectomy [2041]. 6. Status post cholecystectomy gangrenous cholecystitis [2105] 7. Status post gastrojejunostomy. 8. Macular degeneration reportedly legally blind left eye 9. Status post total abdominal hysterectomy bilateral salpingo-oophorectomy. 10. Breast cancer status post modified radical mastectomy [2081] 11. Hypertension. 12. History Methicillin resistant Staphylococcus aureus infection. 13. Multiple falls. 14. status post ileocolectomy colon cancer [1-2] 15. osteoarthritis 16. reported history hepatitis [2064] 17. status post partial hysterectomy [2061] 18. status post ventral incision hernia repair [2095] Social History: nursing home resident, formerly lawyer, per daughter cognitively baseline intact, writing life memoir recent surgery, left quite ill. Family History: Noncontributory Physical Exam: Exam admission floor (from ICU) limited pt's mental status. Gen: sleeping, arousable following commands, breathing comfortably, heart RRR 2/6 SEM LSB, lungs crackles L mid base anteriorly, abd soft, non distended, incision site C/D/I. Peripheral pulses easily palpable Neuro: follows commands, intermittently wiggle toes, unclear command CN: R pupil 3--2, L pupil surgical, +OC's purposeful EOM's, face symmetric, tongue midline, +gag M: moves 4 extremities vigorously mild painful stimuli, moves LUE less others. S: localizes pain 4 R: RUE LUE 1+ throughout, patellae 1+ bilaterally, 5 beats ankle clonus non sustained bilaterally, toes bilaterally, +jaw jerk, -[Doctor Last Name ] Pertinent Results: [2115-1-20] 11:54AM TYPE-ART TIDAL VOL-500 O2-100 PO2-437* PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2 AADO2-252 REQ O2-49 INTUBATED-INTUBATED [2115-1-20] 11:54AM O2 SAT-100 [2115-1-20] 09:51AM CEREBROSPINAL FLUID (CSF) PROTEIN-49* GLUCOSE-64 LD(LDH)-50 [2115-1-20] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1550* POLYS-73 LYMPHS-26 MONOS-1 [2115-1-20] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-2550* POLYS-67 LYMPHS-30 MONOS-3 [2115-1-20] 08:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2115-1-20] 08:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2115-1-20] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2115-1-20] 07:38AM TYPE-ART PO2-301* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 INTUBATED-NOT INTUBA [2115-1-20] 07:38AM GLUCOSE-112* LACTATE-3.3* NA+-131* K+-4.4 CL--99* [2115-1-20] 07:38AM HGB-11.5* calcHCT-35 O2 SAT-99 CARBOXYHB-0.4 MET HGB-0.7 [2115-1-20] 07:38AM freeCa-1.10* [2115-1-20] 07:20AM GLUCOSE-93 UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 [2115-1-20] 07:20AM ALT(SGPT)-9 AST(SGOT)-31 AMYLASE-141* TOT BILI-0.5 [2115-1-20] 07:20AM WBC-7.8 RBC-3.95# HGB-11.8# HCT-36.7 MCV-93 MCH-30.0 MCHC-32.3 RDW-14.1 [2115-1-20] 07:20AM NEUTS-82.0* LYMPHS-14.9* MONOS-2.7 EOS-0.3 BASOS-0.2 [2115-1-20] 07:20AM PLT COUNT-472# Brief Hospital Course: ICU/Floor course system: Neuro: 1. First time seizures - episode thought focal status, stopped never recurrent seizure-like activity. thought perhaps seizure secondary severe electrolyte abnormalities setting poor nutrition post operatively. continued dilantin, initially 100 mg IV TID, levels persistently supratherapeutic upon transfer floor dilantin held day levels checked. [1-29] level finally within low-therapeutic range (4.4, corrected albumin approximately 9) restarted 100 mg qday. thought intrinsic slow clearance dilantin, none medications known decrease dilantin clearance. Upon discharge level 3.7. levels followed 2x/week. neurologic workup seizure included LP unremarkable MRI showed enhancing lesions, one small area DWI right thalamus without FLAIR correleate unclear significance. Radiology reported diffuse meningeal uptake, likely s/p LP effects. EEG performed. 2. Encephalopathy - Pt initially encephalopathic, thought due infection well dilantin toxicity. pneumonia treated dilatnin level reduced, became markedly awake lucid, discharge conversant easily following commands. ID: 1. Aspiration pneumonia - LLL infiltrate CXR, leukocytosis 13K, low grade temp (98.8 ax), started levofloxacin flagyl completed 10 day course. wbc 6 upon discharge lung exam much improved. blood urine cultures negative date. Pulm: intubated [1-20] airway protection multiple sedating medications received seizure. easily extubated 6pm [1-21]. [1-24] episode acute respiratory distress, CXR lung exam consistent pulmonary edema given IV lasix excellent response. started maintenance dose lasix remainder stay discontinued upon discharge. Heme: admission, hct dropped 36->29, repeat 32 appear iron deficiency anemia chronic disease, however borderline low B12 folate. Stool guiaic's negative. hct stayed around 28-29 remainder stay. Pain: Continued fentanyl patch (for OA) prevent withdraw, prn tylenol. FEN: Pt PO'ing due encephalopathy. Upon transfer, nutrition consulted plan PICC placement TPN made. PICC placed able placed peripherally, therefore started [Month/Year (2) 32813]. Electrolytes followed daily initial hyponatremia resolved. also initially hypomagnesemia, hypocalcemia, hypokalemia, stabilized [Month/Year (2) 32813]. [1-28] passed speech/swallow evaluation oral diet started. tolerated well upon discharge [Month/Day (4) 32813] discontinued plans augment oral nutrition well possible. daughter met medial nutrition group prior discharge. electrolytes followed weekly. also restarted pancrease eating full diet. PPx: stroke ppx, initially given ASA, due decreasing hct recent surgery, upon transfer ASA d/c'ed. DVT prophylaxis receive heparin [Last Name (LF) 32813], [First Name3 (LF) ] given SC heparin, started back SC heparin upon discharge. GI prophylaxis receiving pepcid, switched back home regimen protonix upon discharge. Code: intially DNR DNI, much discussion daughter PCP [Last Name (NamePattern4) ]. [First Name (STitle) ] decision made make DNR/DNI. Dispo: transferred back nursing home much improved condition [2115-1-31]. Medications Admission: 1. Zestril 10mg daily 2. Protonix 40mg daily 3. Pancrease 3 packets per meal 4. Fentanyl patch 25mcg/hr every 72 hours. 5. Ocuvite twice daily Discharge Medications: 1. Multi-Vitamin Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s)* Refills:2 2. Ocuvite Tablet Sig: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 3. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1) Injection three times day. Disp:qs Refills:2 4. Dilantin 100 mg qday 5. Protonix 40 mg qday 6. Fentanyl patch 7. Zestril 10 mg qday 8. Multivitamin Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Partial seizure Pneumonia Discharge Condition: improved Discharge Instructions: Please return ED pt develops worsening respiratory distress seizure-like activity. taking complete diet restarted pancrease dilantin level electrolytes followed weekly. CHeck albumin dilantin level. Followup Instructions: Dr. [Name (NI) ], pt schedule	[ "4280", "2859", "4019" ]
Admission Date: [2114-11-18] Discharge Date: [2114-11-19] Date Birth: Sex: Service: DIAGNOSIS: Right temporal intracranial mass. HISTORY PRESENT ILLNESS: 53-year-old gentleman presented vertigo ringing ears headache since [Month (only) 359]. C-scan MRI without gadolinium outside hospital, diagnosed 3-cm x 3-cm intracranial right temporal mass. referred [Hospital1 188] evaluation. HISTORY PRESENT ILLNESS: patient history headache, ringing ears, vertigo since [Month (only) ] early [Month (only) 359]. history nausea, vomiting, visual disturbance, diplopia, seizures. evidence weakness tingling numbness anywhere. admission, patient found mass edema around bleeding surrounding tumor. admitted Intensive Care Unit blood-pressure control anti-seizure medication therapy close monitoring. workup revealed left lung mass adrenal mass; preliminary diagnosis carcinoma lung extensive metastasis made. workup required. patient expressed explicit desire home [Holiday ] Eve [Holiday ] intentions staying hospital [Holiday ] Day. Therefore, started high-dose Decadron anti-edema measures. discharged home high-dose Decadron. followup. us scheduled CT guided lung biopsy [3-22] [Hospital Unit Name 1825] 9:30 am. also continue Decadron 8 mg p.o. q.6h. two days 6 mg Decadron q.6h. two days followed 4 mg Decadron q.6h. meets Dr. [Last Name (STitle) 724] Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Brain [Hospital 341] Clinic [2114-11-26]. Based tissue diagnosis, patient eyelid surgery chemotherapy chemotherapy radiotherapy, decided. patient also given strict instruction contact us earliest date change mental status severity headache. ALLERGIES: patient allergic LIPITOR SULFA. new allergy DILANTIN documented. DISCHARGE MEDICATIONS: 1. Zantac 150 mg p.o.b.i.d. 2. Depakote 350 mg p.o. three times day. 3. Decadron starting 8 mg, tapering 4 mg p.o. q.6h. followup plans made. patient also noted past medical history coronary artery disease three-vessel stenting angioplasty; hypertension; diabetes mellitus, takes Insulin. DISCHARGE CONDITION: patient awake, alert, oriented, localizing signs, focal lesions. patient fully aware risks discharged. patient willing go home. DR.[Last Name (STitle) ],[First Name3 (LF) ] 14-120 Dictated By:[Last Name (STitle) 22910] MEDQUIST36 D: [2114-11-21] 10:43 T: [2114-11-21] 12:44 JOB#: [Job Number 24026]	[ "4019" ]
Admission Date: [2175-8-10] Discharge Date: [2175-8-22] Date Birth: [2148-2-15] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 6565] Chief Complaint: Right flank pain, fever Major Surgical Invasive Procedure: embolization bleeding artery IR History Present Illness: 27 F 2 days right flank pain, sharp, worsened deep breaths. similar pains past. Associated fatigue fevers x 2 days. dysuria, hematuria urinary symptoms. Chronic tingling right foot (since diagnosed cord compression many months back. headache. ER course - given Abx below. Temp 103.9 ROS: Constitutional: Fatigued, weight loss past 5 weeks. Fever associated chills above. Also anorexic. Neuro: confusion, numbness extremities, dizziness light-headedness, vertigo, weakness extremities, confusion, tremor. Parasthesias-as Psychiatric: depression, suicidal ideation Eyes: blurry vision, diplopia, loss vision, photophobia. Wears glasses. ENT: dry mouth, oral ulcers, bleeding nose, gums, tinnitus, sinus pain, sore throat Cardiac: chest pain, DOE, syncope, PND, orthopnea, palpitations, peripheral edema Pulmonary: shortness breath, hemoptysis, pleuritic pain. chronic coung many weeks GI: nausea vomiting. diarrhea, constipation, hematemesis, melena, hematochezia. Abd pain above. Heme: easy bleeding, bruising, lymphadenopathy GU: dysuria, hematuria, increased frequency, urgency incontinence Endocrine: Lost hair since starting chemo. skin changes, heat cold intolerance Skin: rash pruritis Musculoskeletal: myalgias, arthralgias, back pain Allergy: seasonal allergies- NKDA. . [x] systems negative detailed review except noted. Past Medical History: - Hepatocellular carcinoma - metastasis bone, lung, abdomen -Had receiving weekly 5-FU leucovorin progressed weekly doxorubicin. previously treated gemcitabine, Cisplatin, Avastin. - Pulmonary embolism SVC clot - anticoagulation. -R ovarian cyst-She affirms increasing abdominal girth [2168], feeling increased bloating, presented ED found right ovarian cyst, resected. - [2155] (7yrs old) hospitalized 6 months fever/cough, weakness, unclear source infection, require blood transfusions. - Gyn- menstrual periods past year Social History: Social History: Lives sister brother. Recently relocated [Country 3587] [12-21] - speaks Creole Portugese. Denies stds, denies etoh, ivdu, smoking. Family History: 1 sister age 27, question R leg mass resected 4 yrs ago. Brother liver problems child. Father - HTN Denies cancer history Physical Exam: VS 99.6 P 123/min, BP 104/68 RR 16 100% RA Gen - Thin female appears chronically sick. acute distress. Eyes - pale, jaundiced ENT - moist mucosae, thrush, ulcers erythema Neck - supple, LAD, JVP normal CV - S1, 2 - normal, murmurs rubs, gallops. Tachycardia RS - crackles wheezing Abd - rt UQ abd pain, RT distenstion. Liver edge palpable. Rt CVA tenderness Extremeties - edema Skin - rash GU - catheter Neuro - Alert oriented x3, Cr n [3-27] normal. Motor - [5-20] UE LE bilaterally equal, prox distal. Sensory normal crude touch bilaterally. Plantars flexor bilaterally. pronator drift. Fluent speech. Psychiatric - anxious. Calm. depressed Heme/lymph - cerv LAD, thyroid normal. Pertinent Results: CXR - IMPRESSION: acute cardiopulmonary process. Multiple pulmonary masses present lung base better evaluated CT examination [2175-7-26] CT abdomen, pelvis - IMPRESSION: 1. Significant interval worsening metastatic disease described above. 2. Interval increase size left adnexal dermoid. 3. Unchanged appearance osseous metastasis . . Brief Hospital Course: # acute blood loss anemia/hemoperitoneum: Likely bleeding hepatic tumors, however, angio identify obviously bleeding lesions, embolization performed initially. Pt increased abdominal distension pain; repeat CT scan show demonstrable change hemoperitoneum, could rule continued oozing liver lesions. R hepatic artery therefore embolized Gel-foam prevent further/future bleeding. Following procedure, patient stable hematocrit, require additional transfusions. . # Fevers: clinical signs would indicate current infection, pt w/o cough, SOB, dysuria, diahrea. Serial blood cultures without crowth. Fevers believed secondary either diffuse cancer blood peritoneum. . # Pain: Pt swtiched PCA MS contin w/ diluadid PRNs. patient significantly uncomfortable admission, pain ins well controlled time discharge. Pain due carcinomatosis abdomien. . # hepatocellular carcinoma: HepB +, widely metastatic. last chemo 2 weeks ago. pt failed multiple chemotherapeutic regimens, felt would gain advantage additional treatment. Pt seen palliative care, assistance appreciated. Patient discharged home hospice. Medications Admission: LOVENOX 60MG subcutaneously [Hospital1 ] Discharge Medications: 1. Roxanol Concentrate 20 mg/mL Solution Sig: [1-17] mL PO q 1 hour needed discomfort/respiratory distress. Disp:4 syringes Refills:0 2. Wheelchair Misc Sig: One (1) Miscellaneous day. Disp:1 Refills:0 3. hospital bed please provide pt w/ one hospital bed 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 4 Hours) needed Pain. Disp:150 Tablet(s) Refills:2 8. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO Q12H (every 12 hours). Disp:240 Tablet Sustained Release(s) Refills:2 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times day) needed. Disp:250 ML(s) Refills:1 10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed nausea. Disp:50 Tablet(s) Refills:2 Discharge Disposition: Home Service Facility: VistaCare Discharge Diagnosis: Metastatic liver cancer hemoperitoneum Discharge Condition: Stable Discharge Instructions: discharged admission due bleeding belly. bleeding one liver tumors. blood suppy tumor blocked bleed. bleeding tumors, longer canidate serafinib treatment. Unfortuantly chemotherapy normally use treat liver cancer proven successful. discharged home, arangements made give support remain comfortable. Followup Instructions: Call Dr. [Last Name (STitle) ] develop severe abdominal pain, confusion, difficulty breathing, vomiting. [First Name4 (NamePattern1) 2946] [Last Name (NamePattern1) ] MD [MD Number(1) 3218]	[ "2851" ]
Admission Date: [2118-12-2] Discharge Date: [2118-12-16] Date Birth: [2039-1-27] Sex: Service: SURGERY Allergies: Ativan / Morphine Attending:[First Name3 (LF) 2836] Chief Complaint: weakness, abdominal pain Major Surgical Invasive Procedure: None Attempted IV Port placement History Present Illness: patient 79y man end ileostomy, well-known surgery service recently discharged [11-30], returns ED 24h peristomal abdominal pain weakness. pain began day following discharge, describes constant dull pain, non-radiating. also complains weakness. ostomy out-put within normal limits patient. out-put liquid visible blood. denies dizziness, fever, chills. one episode emesis morning presentation. SBP admission ED 70s. PMH: 1. Gout 2. Hypertension 3. atrial fibrillation 4. h/o spontaneous pneumothorax 5. ? pulmonary fibrosis 6. h/o rheumatic fever 7. h/o multiple small bowel obstructions 8. carotid artery stenosis 9. brain infarct asymptomatic 10. h/o recent c.diff 11. GERD 12. Chronic renal insufficiency 13. h/o Port-a-cath 14. Colonic stricture chronic small bowel obstruction, partial. PSH: 1. Colectomy, ileostomy "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal 2 years ago 3. Lysis adhesions [2118-7-5] 4. Appendectomy 5. Removal cyst neck 6. Left hip replacement 7. Removal 2 burs elbows 8. s/p talc pleurodesis ([Hospital1 112]) 9. s/p port removal staph sepsis 10. Resection ileocolic anastomosis creation end-ileostomy ([11-2]) Past Medical History: PSH: 1. Colectomy, ileostomy "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal 2 years ago 3. Lysis adhesions [2118-7-5] 4. Appendectomy 5. Removal cyst neck 6. Left hip replacement 7. Removal 2 burs elbows 8. s/p talc pleurodesis ([Hospital1 112]) 9. s/p port removal staph sepsis 10. Resection ileocolic anastomosis creation end-ileostomy ([11-2]) Social History: Social History: Quit smoking 35 years ago. ETOH. Family History: Family History: Noncontributory Physical Exam: VS: 97.5 85 122/56 17 1003L Gen: acute distress CV: RRR S1 S2 Lungs: coarse breath sounds bilaterally, rales wheeze Abd: soft, non-distended, moderate tympany, tender palpation diffusely primarily around ileostomy site. rebound guarding. Ostomy pink healthy appearing. Brown liquid out-put bag. Ext: Warm, well perfused Pertinent Results: Admit Labs CBC: 26/35.9\539 Chem: 128/98/42 ---------<239 5.8\13\2.0 Lactate:7.4 Tbil:0.5 AST:26 ALT:57 AP:96 . [2118-12-2] 01:10PM BLOOD WBC-26.3# RBC-3.66 Hgb-11.8* Hct-35.9* MCV-98 MCH-32.1* MCHC-32.8 RDW-15.1 Plt Ct-539* [2118-12-3] 04:48AM BLOOD WBC-23.5* RBC-3.47* Hgb-11.1* Hct-32.4* MCV-94 MCH-32.0 MCHC-34.2 RDW-15.5 Plt Ct-454* [2118-12-13] 05:45AM BLOOD WBC-12.6* RBC-2.92* Hgb-9.4* Hct-27.7* MCV-95 MCH-32.2* MCHC-34.0 RDW-16.4* Plt Ct-422 [2118-12-11] 04:25AM BLOOD PT-27.8* INR(PT)-2.8* [2118-12-2] 01:10PM BLOOD Glucose-239* UreaN-42* Creat-2.0* Na-128* K-5.8* Cl-98 HCO3-13* AnGap-23* [2118-12-3] 04:48AM BLOOD Glucose-132* UreaN-37* Creat-1.5* Na-132* K-5.5* Cl-102 HCO3-18* AnGap-18 [2118-12-13] 05:45AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-131* K-4.8 Cl-101 HCO3-22 AnGap-13 [2118-12-5] 03:54AM BLOOD ALT-27 AST-18 LD(LDH)-151 AlkPhos-54 Amylase-36 TotBili-0.5 [2118-12-13] 05:45AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.9 [2118-12-7] 04:30AM BLOOD TSH-13* [2118-12-7] 04:30AM BLOOD Free T4-0.91* [2118-12-6] 06:15AM BLOOD Digoxin-0.7* [2118-12-2] 01:28PM BLOOD Lactate-7.4* [2118-12-3] 05:04AM BLOOD Lactate-3.0* [2118-12-5] 04:17AM BLOOD Lactate-0.6 . [2118-12-5] 11:08 MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [2118-12-6]): POSITIVE METHICILLIN RESISTANT STAPH AUREUS. . Radiology Report CT PELVIS W/CONTRAST Study Date [2118-12-2] 2:10 PM IMPRESSION: 1. Significant small bowel dilation fecalization proximal right mid abdominal anastomosis concerning massive impaction. Stricture stoma cannot excluded. Small amount free intra- abdominal air pneumatosis several loops ileum deep within pelvis concerning ischemic process. 2. Unchanged aneurysm (x2) infrarenal abdominal aorta. . Brief Hospital Course: patient 79yM w/ end ileostomy presenting w/ abdominal pain weakness, found small foci free air pneumatosis ileum proximal ostomy. admitted surgery started IVF resuscitation dehydration, weakness elevated Lactate. CT scan done showed fecal impaction disimpacted emergency room. also demonstrated small foci free air possible pneuomotosis proximal illeum. Currently reports significant improvement abdominal pain since disimpaction. Vascular consulted due history superior mesenteric artery stent mesenteric ishemia resection ileocolic anastomosis creation end-ileostomy. presented increased watery ostomy output parastomal abdominal pain. Review CT scan shows stent patent unlikely mesenteric ischemia. Leukocytosis: started Zosyn 1 week course WBC defervesced. C.diffs negative. Hyponatremia/Hyperkalemia: Improved hydration Hypotension/Hemodynamic Instability: Dehydrated improved hydration. diet advanced eating well. ostomy output 1-liter/day. ordered Opium Tincture Psyllium 1.7 g Wafer. abdomen soft nontender nondistended. IV Port attempted, successful. needs continued close monitoring I&O's. Medications Admission: protonix 40', amiodarone 200'', digoxin 0.125', lopressor 12.5''', Tylenol prn, Imodium 2mg tab''', coumadin (for afib, 3mg/d), levothyroxine 50mcg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Monitor INR. 5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QID (4 times day). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Opium Tincture 10 mg/mL Tincture Sig: Three (3) Drop PO TID (3 times day): 0.3mL. Titrate according stool consistency. Avoid constipation. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Abdominal pain Weakness Leukocytosis Elevated Lactate 7.4 Hyponatremia/Hyperkalemia Hypotension Hemodynamic Instability Dilated loops small bowel fecalization distal ileum Acute Renal Failure Discharge Condition: Good Discharge Instructions: admitted dehydration, weakness hemodynamic instability. Please call doctor return ER following: * experience new chest pain, pressure, squeezing tightness. * New worsening cough wheezing. * vomiting cannot keep fluids medications. * getting dehydrated due continued vomiting, diarrhea reasons. * Signs dehydration include dry mouth, rapid heartbeat feeling dizzy faint standing. * see blood dark/black material vomit bowel movement. * skin, whites eyes become yellow. * pain improving within 8-12 hours gone within 24 hours. Call return immediately pain getting worse changing location moving chest back. * shaking chills, fever greater 101.5 (F) degrees 38(C) degrees. * serious change symptoms, new symptoms concern you. . * Take new meds ordered. * drive operate heavy machinery taking narcotic pain medication. may constipation taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); continue drinking fluids, may take stool softeners, eat foods high fiber. * Continue increase activity daily * Continue Ostomy care Followup Instructions: Please follow-up Dr. [First Name (STitle) ] [2-27] weeks. Call [Telephone/Fax (1) 2998] schedule appointment. Completed by:[2118-12-15]	[ "5849", "2449" ]
Admission Date: [2120-11-9] Discharge Date: [2121-1-9] Service: [Hospital1 ] HISTORY PRESENT ILLNESS: patient 83 year-old female history rectal cancer admitted [Hospital1 69] [2120-11-9] low anterior resection rectal cancer ileostomy omental flap placement stump. initially course complicated necrosis omental pouch prolonged postoperative ileus. Multiple CT scans abdomen revealed evidence obstruction ileus thought secondary inflammation irritation necrotic omentum. [12-18], patient found less responsive increasing respiratory effort. arterial blood gas revealed pH 7.22, CO2 100 PA2 84 3 liters oxygen. point patient intubated hypercarbic respiratory failure transferred Medical Intensive Care Unit. respiratory standpoint, patient extubated following day, required reintubation three days secondary increasing secretions need constant pulmonary toilet. patient remained difficult wean. attributed volume overload secondary diastolic dysfunction well component chronic obstructive pulmonary disease. sputum culture [12-18] subsequently grew MRSA patient treated ten day course Vancomycin. patient finally extubated [1-5] extensive diuresis. gastrointestinal standpoint CT abdomen [12-16] revealed communication Hartmann's pouch peritoneal cavity abdominal fluid collection. Per Surgery Service collection noted draining rectal stump recommended surgical management. infectious disease standpoint four four blood culture bottles [12-5] [12-6] grew coag negative staphylococcus, treated Vancomycin. Surveillance cultures [12-28] revealed growth date. mentioned previously, patient sputum [12-18], grew MRSA. Blood cultures [12-18] subsequently grew [Female First Name (un) ] [Female First Name (un) 29361], patient completed fourteen day course Fluconazole [1-4]. Lastly, sputum [1-4] grew Pseudomonas. Infectious Disease Service consulted believed patient colonized, particularly since currently evidence pneumonia. cardiac standpoint concern volume overload secondary diastolic dysfunction. patient echocardiogram [12-19], revealed left ventricular ejection fraction 55% unremarkable chamber sizes thicknesses. also concern coronary artery disease. patient reportedly cardiac catheterization outside hospital 30% left anterior descending coronary artery 50% right coronary artery. several episodes atypical chest pain stay ruled myocardial infarction multiple times. MICU stay patient frequent episodes paroxysmal atrial fibrillation. treated Amiodarone Lopressor good effects. nutrition standpoint patient initially total parenteral nutrition, discontinued [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361] fungemia. patient since tube feeds via nasogastric tube goal. psychiatric standpoint patient profoundly depressed followed Psychiatry Service. episode self extubation attempt. point feel suicide risk. tried Celexa Ritalin without benefit. currently Wellbutrin. PAST MEDICAL HISTORY: 1. Rectal carcinoma status post radiation therapy chemosensitization low anterior resection [2120-11-15]. 2. Hypertension question diastolic dysfunction. 3. Coronary artery disease 30% left anterior descending coronary artery, 50% right coronary artery. 4. Status post cholecystectomy. ALLERGIES: Penicillin, Erythromycin intravenous contrast (but tolerate contrast). MEDICATIONS TRANSFER: Lopressor 50 mg po b.i.d., Wellbutrin 100 mg po t.i.d., Lasix 80 mg po b.i.d., Prevacid 30 mg po q.d., Amiodarone 400 mg po q.d., Atrovent, Colace 100 mg po b.i.d., Reglan 10 mg po q.i.d., heparin subQ, Tylenol prn. SOCIAL HISTORY: lives husband. positive tobacco history. PHYSICAL EXAMINATION: patient temperature 99.9. blood pressure 129/34. Heart rate 78. Respiratory rate 30. sating 100% 4 liters oxygen nasal cannula. general, patient sad, conversant older female acute distress. Neck examination jugulovenous pressure approximately 8 cm water. neck supple without lymphadenopathy. Cardiovascular examination regular rate rhythm. murmurs, rubs gallops. Respiratory examination, patient decreased breath sounds bilaterally well soft bibasilar rales. Abdomen examination patient positive bowel sounds. abdomen soft, nontender, nondistended. colostomy site clean intact. extremities warm without clubbing, cyanosis edema. 2+ dorsalis pedis pulses bilaterally. LABORATORY: patient white blood cell count 11.6, hematocrit 32.2, platelet count 376, sodium 137, potassium 4.8, chloride 88, CO2 41, BUN 15, creatinine 0.4, calcium 9.1, mag 1.8, phosphate 4.3. Studies, patient chest x-ray [1-6], revealed interval improvement upper zone redistribution small left pleural effusion residual left lower lobe collapse questionable consolidation retrocardiac region thought secondary atelectasis. CT abdomen [12-25], revealed collection fluid air within abdomen consistent abdominal abscess. CT adomen [12-16], revealed collection fluid air within abdomen identifiable Hartmann's pouch. TTE [12-19]. found ejection fraction 60%. left atrium mildly dilated. left ventricular thickness cavity size normal. right ventricular thickness size normal. found moderate mitral annular calcification 1+ mitral regurgitation. Microbiologic data, sputum culture [1-4] grew Pseudomanas. [12-28] MRSA, [12-22] MRSA [12-18] MRSA. Blood cultures [12-28] growth times two sets. [12-18] one four [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361], [12-6] two two coag negative staph. [12-5] two two coag negative staph. [11-27] growth times two. HOSPITAL COURSE: patient transferred General Medicine Service [1-6] management. 1. Pulmonary: patient daily chest physical therapy aggressive pulmonary toilet. encouraged use incentive spirometer. decided treat patient course Ciprofloxacin Pseudomonas sputum. discussed treatment infectious disease fellow think needed double covered pan sensitive Pseudomonas sputum. patient's respiratory status continued improve daily basis. oxygen saturations improved dramatically point required 3 4 liters nasal cannula maintain appropriate oxygen saturation. 2. Infectious disease: mentioned previously treated patient empirically Pseudomonas pneumonia Ciprofloxacin. clear evidence pneumonia, given history tenuous status opted treat empirically single [Doctor Last Name 360]. infectious disease standpoint patient well. overt signs infection. followed blood cultures carefully additional growth date surveillance cultures. white blood cell count fever curve remained within normal limits. 3. Gastrointestinal: patient noted abdominal collection draining rectal stump. followed Surgery Service stay believe needed surgical management. abdominal examination remained benign. 4. Cardiovascular: cardiovascular standpoint evidence acute ischemia, however, stay Medical Intensive Care Unit patient several episodes paroxysmal atrial fibrillation. continued Amiodarone Lopressor. Despite several episodes stay general medicine floor. time remained hemodynamically stable ventricular response rate 150s. responded quite well low dose intravenous Lopressor converting sinus rhythm almost instantaneous. think atrial fibrillation secondary patient's general medical problems. Toward end hospital stay patient remained normal sinus rhythm. Despite opted continue Amiodarone Lopresor. stay Medical Intensive Care Unit, patient felt diastolic dysfunction, noted fluid sensitive responsive Lasix. time arrived medical floor felt euvolemic. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Last Name (NamePattern1) 11732] MEDQUIST36 D: [2121-3-18] 17:00 T: [2121-3-19] 05:41 JOB#: [Job Number 36073]	[ "4280" ]
Admission Date: [2117-7-18] Discharge Date: [2117-7-29] Date Birth: [2047-11-12] Sex: Service: MEDICINE HISTORY PRESENT ILLNESS: patient 69 year-old male history coronary artery disease status post myocardial infarction transferred [Hospital1 346] percutaneous angioplasty seven minute episode ventricular tachycardia without intervention. patient found bed wife, choking unresponsive mid afternoon day admission. wife called daughter turn activated Emergency Medical System. patient found V fibrillation treated epinephrine, atropine Dopamine. taken [Hospital 35774] Hospital given Lidocaine Amiodarone. Electrocardiogram notable ST depressions V4 5 6 leads junctional rhythm. transferred [Hospital1 69] emergent cardiac catheterization. Cardiac catheterization notable mild moderate left anterior descending coronary artery stenosis stenting first diagonal performed. transferred floor sedated intubated. PAST MEDICAL HISTORY: Significant hypertension, life long, coronary artery disease, questionable myocardial infarction [2108], percutaneous transluminal coronary angioplasty [2116-6-14], left anterior descending coronary artery 95% stenosis, OMI 90% stenosis, obtuse marginal one stent diabetes apparently diet controlled. ALLERGIES: known drug allergies. FAMILY HISTORY: Significant coronary artery disease. patient's father died age 57 acute myocardial infarction. SOCIAL HISTORY: patient 80 pack year history smoking [2115]. ethanol. engineer married children. MEDICATIONS ADMISSION: Zocor 40 day, Plendil 5 day, atenolol 25 day Vaseretic dose unknown. PHYSICAL EXAMINATION: Temperature 99.8. Heart rate 66. Blood pressure 124/61. patient intubated AC 600 tidal volume 14 respirations FIO2 40% PEEP 5. physical examination intubated, sedated, spontaneous monoclonic jerks. HEENT pupils small, minimally reactive light. gag reflex. Cardiovascular regular rate rhythm. murmurs. Pulmonary clear auscultation anteriorly. Abdomen nondistended, soft. Extremities positive pulses four extremities. patient paroxysmal monoclinic jerks. Neurological examination eyes open spontaneously. tracking. roving eye movements. response verbal painful stimuli. Cranial nerves examination pupils 2 mm light reaction appreciated except possible minimal change left pupil. corneal reflex bilaterally. blink light bilaterally. Slide eye movements, response ________ testing. gag obtainable. Motor increased tone throughout normal bulk intermittent myoclonic movements four extremities increase frequency patient stimulated. drawer, flexor extensor response pain. patient protect face arm drop towards it. Reflexes 3+ brachial radialis biceps triceps reflexes, left right arms. 3+ triceps reflexes bilaterally, 2+ patella reflexes bilaterally 4+ ankle reflexes bilaterally. plantar movements. patient positive [Doctor Last Name ] sign bilaterally upper extremities three four beats clonus ankles. LABORATORY: White blood cell count 10.0, hematocrit 41.5, platelets 165, sodium 145, K 3.3, chloride 105, bicarb 19, BUN 20, creatinine 1.6, glucose 237. Arterial blood gas pH 7.3, PCO2 46, PO2 292, calcium 8.4, total bilirubin 0.4, CPK 44, alkaline phosphatase 83, troponin less 0.4. HOSPITAL COURSE: Immediately upon admission neurological consult obtained indicated wide spread severe anoxic brain damage. CT scan head done showed small subcortical hemorrhage left frontal lobe multiple lacunar infarcts, chronic reduced great white matter visibility consistent global ischemic change. Given patient's history started Amiodarone prevent arrhythmias. also hypertensive started Lopressor, aspirin, Plavix, statin, Captopril. Since admission patient started spiking low grade fevers started Flagyl Levofloxacin empiric treatment possible infection. Since beginning [Hospital 228] hospital stay multiple meetings patient's family undertaken primary care team neurology team attempt explain poor prognosis, according neurology given patient's status 93% improvement 7% slight improvement severe neurologic damage, 0% moderate complete improvement patient's neurological status. patient's family voiced understanding current situation decided proceed tracheostomy PEG tube placement maintain patient full code. [7-23] tracheostomy tube performed bedside interventional pulmonology without complications. PEG tube placement performed GI [7-27]. patient extubated [7-28] early a.m. remained stable next 24 hours flow oxygen 35%. cardiovascular status remained stable high normal blood pressures cardiac rhythm significant intermittent atrial fibrillation spontaneous conversion sinus bradycardia without requiring intervention. Infectious disease wise remained afebrile since initiation antibiotic treatment. neurological status remained unchanged. patient vegetative state time discharge. patient discharged [Hospital3 ] Hospital Naddick long term care management diagnosis acute myocardial infarction status post ventricular fibrillation anoxic brain injury. discharge medications insulin sliding scale per flow sheet, calcium gluconate 500 po t.i.d., Lansoprazole oral solution 30 mg nasogastric q.d., heparin 5000 units subQ q 12, aspirin 325 mg po q day, Metoprolol 75 mg nasogastric b.i.d. held systolic blood pressure less 100 heart rate less 60, Captopril 75 mg po t.i.d. held systolic blood pressures less 90. Saliva substitute 1 3 milliliters po q 1 2 hours prn, Metronidazole 500 mg intravenous q 8 last dose [8-1]. Acetaminophen 325/650 po q 4 6 hours prn fever pain, Levofloxacin 500 mg po q 24 hours last dose given [8-1]. Simvastatin 40 mg po q day Plavix 75 mg po q.d. last dose [2117-8-18]. Aspirin 325 mg po q day Atropine sulfate 0.5 mg intravenous prn symptomatic bradycardia hypertension. discharged tube feeding diet. staff [Hospital3 ] Hospital Naddick schedule primary care physician follow patient. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-222 Dictated By:[Doctor First Name 35775] MEDQUIST36 D: [2117-7-29] 12:01 T: [2117-7-29] 12:08 JOB#: [Job Number 35776]	[ "4019", "2720" ]
Admission Date: [2153-2-3] Discharge Date: [2153-2-7] Date Birth: [2074-10-16] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 30] Chief Complaint: hypotension, fever 101 Major Surgical Invasive Procedure: femoral central line History Present Illness: 78 yo man c PMH Chronic Liver disease, Hepatoma s/p [First Name3 (LF) 54267] x 2, COPD, Afib coumadin, USOH [2153-2-3] began chills, rigors febrile home 101, per pt. went [Location (un) ] ED found hypotensive BP low 70 s. Pt denies having: cough, SOB, dysuria, urinary frequency, diarrhea, abdominal pain, n/v, night sweats, anorexia. Last BM yesterday. [Location (un) ]: Levaquin, 3 L NS, dopamine 5 mcg/min. Pt arrived [Hospital1 18] ED c BP near 120/48 HR 80-90s. Dopamine drip stopped. However pt noticed refractory hypotension started Levophed again. [Hospital1 ] ED, received IV Vanco, Levoflox, FFP NS IVF 100cc/hour. . MICU course: pt vanc, levo, flagyl unit. Panculture negative date. CXR without infiltrates. Abd u/s negative cholecystitis. Abdominal CT r/o new liver abscess considering pt's PMH negative. Vancomycin tapered [2-6] (received 4 days). IV levoflox flagyl continued. Pt also steroids bronchospasm, COPD MICU, received prednisone 60mg po qd unit, bronchodilators. satting 99-100% 2L NC (his baseline oxygen requirement). Initially, INR supratherapeutic 4.9, coumadin held initially. Coumadin restarted goal INR [1-12]. foley d/c'd continues urinate well. tolerating regular diet, taking meds orally. Past Medical History: -Afib many years coumadin -HTN -COPD -Hepatocellular carcinoma cirrhosis s/p [Month/Day (3) 54267] surgery x 2, dx'd 2 years ago, folloed Dr. [First Name (STitle) ] [Hospital1 18] . Pt hx liver abscess s/p second [First Name9 (NamePattern2) 54267] [5-13]. -Prosthetic rigtht eye s/p HSV subsequent enucleation -Stent pancreas mass h/o obstructive jaundice -Sarcoidosis s/p lung biopsy right -h/o Right temporal infarct [1-11] subtherapeutic INR, Afib MRI, [6-13] -h/o splenic infarct thought [1-11] subtherapeutic INR, Afib [6-13] -last echo [2152-6-13]: EF 55%, mod-markedly dil atria b/l. dil RV free wall hypokinesis, RV pressure overload, 1+MR, 4+TR, severe pulm artery HTN, Cardiologist [Location (un) ] Dr. [Last Name (STitle) 3503], dry weight 162 lbs. Social History: patient lives home wife, independent ADLs, 2 daughters, originally [Name (NI) 4754] since [2103], smoked 2ppd x 20 years quit 40 yrs ago, etoh, drugs. Former construction worker [Location (un) ] gas co. Family History: patient one 11 children. 2 brothers 1 sister strokes, brothers ages 38 50. One brother [Name2 (NI) 499] cancer. seizures run family. Physical Exam: Physical Exam admission: VITALS: 99.7 HR 90-110 afib, 88-96/58-70, 18, 95% 2 Lt GEN: acute distress, pleasant elderly man SKIN: rash , jaundiced [Name2 (NI) 4459]: NC/AT, anicteric sclera, mmm NECK: supple, meningismus , + JVP CHEST: normal respiratory pattern, CTA bilat anteriorly , decreased breath sounds bases CV: irregular irregular rate, murmurs ABD: soft, nontender, nondistended, +BS, liver edge palpable , ascites. EXTREM: edema, 1+ dorsalis pedis pulses, 2+ radial pulses . Phys Exam call MICU: Vitals: Tm: 96.8 Tc: 96.6 BP: 111/64 (99-120/49-69) P: 81 RR: 19-25 O2sat: 98-100% 2L NC. 24 hour I/O 3090/1310 +1780. 8 hour I/O: 1250/2365 -1115. General: Well appearing CM NAD. Pleasant cooperative. Sitting upright chair talking daughter. [Name (NI) 4459]: right eye prosthetic, left eye PERRL, left eye EOMI. nasal discharge. MM slightly dry, OP clear. Poor dentition. JVD mid neck. cervical LAD. Lungs: CTAB CV: Irregularly irregular rhythm. S1 S2 audible. Abd: Soft, NT, ND, Positive BS, ascites. HSM. Ext: peripheral edema. cyanosis/clubbing. Ext warm well perfused. 2+ DP pulses b/l. Pertinent Results: [2153-2-3] 08:00PM WBC-12.2# RBC-2.92 HGB-10.3* HCT-29.8* MCV-102* MCH-35.1* MCHC-34.5 RDW-16.8* [2153-2-3] 08:00PM NEUTS-73* BANDS-11* LYMPHS-11* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2153-2-3] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2153-2-3] 08:00PM PLT COUNT-163 [2153-2-3] 07:45PM LACTATE-1.3 [2153-2-3] 08:00PM PT-43.3* PTT-39.9* INR(PT)-4.9* . [2153-2-3]: CXR IMPRESSION: Cardiomegaly congestive heart failure.Bibasilar atelectasis small bilateral pleural effusions. . [2153-2-4]: Abdominal Ultrasound IMPRESSION: evidence acute cholecystitis cholelithiasis. Patchy areas increased echogenicity right lobe liver likely representing changes associated prior RF ablation. . [2153-2-5] CT TORSO IMPRESSION: 1. Bilateral predominantly peripheral ground glass opacities, new prior study. etiology uncertain, differential diagnosis includes includes infectious inflammatory process, cryptogenic organizing pneumonia, eosinophilic hypersensitivity pneumonia pulmonary edema superimposed severe emphysema. Clinical correlation follow indicated recommended. 2. Stable renal cysts. 3. Stable appearance radiofrequency ablations site. evidence abdominal abscess pseudocyst. 4. Peripheral high attenuation area transiently seen ?perfusion anomaly, described. . CULTURE DATA: [2153-2-3] Blood cx X 4 neg [2153-2-4] Blood cx X 4 neg [2153-2-3] Urine cx growth [2153-2-3]: UA neg nitr, neg leuks, 0-2 WBC, [2-11] RBC, rare bact, 0-2 epi. . Brief Hospital Course: 78 yo man Chronic Liver disease, Hepatoma s/p [Month/Day (1) 54267] x 2, h/o liver abscess, COPD, Atrial fibrillation coumadin admitted fever hypotension, thought septic secondary unclear etiology-- CXR negative infiltrate bilateral pleural effusions (effusions small diagnostic thoracentesis), Urinalysis negative, urine cx negative, blood cx X 4 negative. Pt covered empirically X 4 days Vanco/Levo/Flagyl, d/c Vanco [2153-2-6], continued Levo/Flagyl complete 7 day course given history liver abscess past. . 1. Hypotension, Fever admission thought [1-11] Septic-picture: clear source. However low BP, documented fever OSH, hx chills makes infection likely. Pt started Levofloxacin + Vanc ED Levophed trough peripheral IV. vanc, levo, flagyl MICU. Panculture negative date. CXR without infiltrates. Abd u/s negative cholecystitis. CT torso showing ground glass opacities lungs inflamm vs. infectious, bilateral effusions small tap. intraabd abscess. - Plan continue Levo/Flagyl 2 days complete 7 day course given h/o liver abscess past. . 2. Cardiovascular: A. Coronaries: signs ischemia EKG, enzymes negative. Aspirin held beta blocker continued. B. Pump: signs ischemia EKG enzymes. Getting 20mg IV lasix diuresis, transitioned 40mg po lasix transfer medical floor. note, usually gets 80mg po qd lasix home. Last echo [6-13] showing EF 55%, severe pulm HTN, dil atria b/l, dilated right ventricle pressure overload. discharge, monitor daily weight call PCP weight increases 3 lbs more, may indicate heart failure. C. Rhythm: Atrial fibrillation. continue beta blocker, atenolol, rate control, coumadin anticoagulation. Goal INR [1-12]. pt goal INR 1mg coumadin po qday. . 3. COPD: Started prednisone 60mg qday total 5 days, completed hospitalization. continue bronchodilators. Pt satting well 2L NC, baseline oxygen requirement. satting well ambulating physical therapy. . 4. GI: Pt hx liver disease, hepatocellular carcinoma status post [Month/Day (3) 54267]. LFTs elevated, AFP high, however stable trending downward. abd pain, nausea, vomiting, diarrhea, constipation. intraabdominal abscess seen CT abdomen. Stable appearance radiofrequency ablations site CT Abdomen. . 5. HTN: Pt's blood pressure remained stable, required pressors 48 hours, fluids needed past 24 hours. Taking well po. Restarted Beta blocker [Last Name (un) ] tight hold parameters. . 6. Code: Pt full code. Medications Admission: 1. Aspirin 81 mg Tablet 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk Device Sig: 4. Atenolol 25 mg Tablet Sig 5. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO day. 7. LT4 25 ug QD 8. Lasix 20 QD Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:3 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 2 days. Disp:2 Tablet(s) Refills:0 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): need see Dr. [Last Name (STitle) 8521] refills monitor INR lab values/adjust dose. . Disp:30 Tablet(s) Refills:0 5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): need follow Dr. [Last Name (STitle) 8521] refills, check electrolytes. Disp:60 Tablet(s) Refills:0 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 2 days. Disp:6 Tablet(s) Refills:0 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours needed wheezing. Disp:1 MDI Refills:2 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times day). Disp:1 MDI Refills:2 Discharge Disposition: Home Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: 1. Hypotension 2. Atrial fibrillation 3. Hypertension 4. Chronic Obstructive Pulmonary Disease 5. Hepatocellular carcinoma 6. history right temporal infarct 7. history splenic infarct 8. history sarcoidosis status post lung biopsy right 9. history prosthetic right eye Discharge Condition: Stable, Good Discharge Instructions: experience fever, chills, chest pain, shortness breath, abdominal pain, nausea, vomiting, please report emergency room immediately. Please take medications prescribed. Please follow physician. [Name10 (NameIs) ] information below. Followup Instructions: appointment Dr. [Last Name (STitle) 31446] [Name (STitle) 8521], 11:00am, [2-14], [2152]. Please call office [Telephone/Fax (1) 54268] need reschedule appointment. Completed by:[2153-2-7]	[ "4019" ]
Admission Date: [2151-10-1] Discharge Date: [2151-10-5] Date Birth: [2091-12-3] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 13256] Chief Complaint: Altered mental status Major Surgical Invasive Procedure: n/a History Present Illness: 59 yo F w/ PMH alcohol hepatitis C cirrhosis history varices upper GI bleed presents loss consciousnes Guiac positive HCT drop 44-->33 setting intoxicated alcohol developed hematemesis ED. Per ED report, patietn alert oriented x3 admission, intoxicated, hypotensive systolic 70s. given multiple listers fluid developed hematemesis vomiting bright red blood clots. NG tube placed continued vomit blood. started octerotid PPI drip boluses, given dose ceftriaxone vancomycin transffused 2u PRBC. pressures continued low received 4th L fluid prior transfer MICU. arrival MICU, intubated sedated. Review systems: unable obatin patient sedated Past Medical History: - Alcoholic cirrhosis- low grade varices- banded, bleeding past. Peripheral edema (on lasix 20mg daily). 1 pint brandy per day year. tried detox once. Denies withdrawal seizures. - Chronic Back pain - Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown got it, denies IVDU, transfusions. Never liver bx. - Hypertension - Alcoholic cirrhosis- low grade varices- banded, bleeding past. Peripheral edema (on lasix 20mg daily). 1 pint brandy per day year. tried detox once. Denies withdrawal seizures. - Chronic Back pain - Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown got it, denies IVDU, transfusions. Never liver bx. - Hypertension Social History: Lives [Location 686] 16yo son. [Name (NI) ] history alcohol abuse, 10 years. Current smoker. Denies drug use. alcohol detox - relaped shortly thereafter. Drinks [2-8] 1 pint brandy per day though actively trying quit. Family History: Mother MI Sister diabetes. Many family members alcohol abuse Physical Exam: Exam Admission: General: sedateed intubated, NAD HEENT: Sclera anicteric. Intubated blood ETT , unable assess JVP CV: RRR, MRG appreciated Lungs: Rhonchrousou breath sounds bilaterally Abdomen: soft, protuberant nondistended. Hypoactive bowel sounds. GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: sedated inutbated DISCHARGE: O: AF 120s/70s 83-97 18 97%RA Gen: NAD, sitting chair comfortable HEENT: MMM, hallitosis. CV: RRR, normal S1/S2, m/r/g. Pulm: CTAB, wheezes, rhonchi rales. Abd: Soft, non-tender, obese. Neuro: AAO person, place, time, president Pertinent Results: Labs Admission: [2151-10-1] 02:15AM BLOOD WBC-7.2# RBC-3.03* Hgb-11.1# Hct-33.1 MCV-109* MCH-36.7* MCHC-33.5 RDW-16.4* Plt Ct-78* [2151-10-1] 02:15AM BLOOD Neuts-37.2* Lymphs-54.5* Monos-5.9 Eos-1.8 Baso-0.7 [2151-10-1] 09:03AM BLOOD PT-22.6* PTT-34.9 INR(PT)-2.2* [2151-10-1] 02:15AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-138 K-5.1 Cl-104 HCO3-22 AnGap-17 [2151-10-1] 07:40PM BLOOD ALT-28 AST-61* LD(LDH)-161 AlkPhos-97 TotBili-2.5* [2151-10-1] 02:15AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5* [2151-10-1] 02:15AM BLOOD ASA-NEG Ethanol-292* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2151-10-1] 09:13AM BLOOD Type-[Last Name (un) ] pH-7.20* [2151-10-1] 02:36AM BLOOD Lactate-4.8* K-4.6 [2151-10-1] 09:13AM BLOOD freeCa-0.86* Labs Discharge: [2151-10-5] 05:01AM BLOOD WBC-4.5 RBC-2.56* Hgb-8.7* Hct-26.2* MCV-102* MCH-34.0* MCHC-33.2 RDW-21.8* Plt Ct-57* [2151-10-5] 05:01AM BLOOD Glucose-122* UreaN-4* Creat-0.4 Na-136 K-3.5 Cl-107 HCO3-27 AnGap-6* [2151-10-5] 05:01AM BLOOD ALT-27 AST-55* AlkPhos-117* TotBili-1.9* [2151-10-5] 05:01AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9 Imaging: EGD ([2151-10-1]): "Source bleeding identified [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear GE junction, bleeding time endoscopy. interventions done. Otherwise grade varices lower third esophagus stigmata bleeding. Moderate amount old blood clots stomach, sources bleeding identified stomach; Normal mucosa duodenum otherwise normal EGD third part duodenum." Portable Chest ([2151-10-1]): "Single frontal view chest obtained. Cardiac mediastinal hilar contours unremarkable. lungs clear focal consolidation, pleural effusion pneumothorax." Portable Abdomen ([2151-10-1]): "Gaseous distention loop small bowel lower abdomen, paucity gas remaining throughout abdomen. findings nonspecific, cannot exclude partial small-bowel obstruction. evidence free intraperitoneal air, though image quality limits assessment. Nasogastric tube place. Right-sided pelvic catheter consistent central venous access line." Brief Hospital Course: 59 year old female history hepatitis C alcoholic cirrhosis known Grade varices presented UGIB secondary [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear. #UGIB- patient history esophageal varices followed Dr. [Last Name (STitle) ] cirrhosis. nadalal one home medications. developed hematemesis ED, received 3L crystalloid 2 units PRBC. trasnferred MICU, EGD performed GI revealed [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tears esophagus. monitored MICU HCT remained stable throughout MICU stay. started sucralfate received 48 hours protonix drip. transfer floor, continued remain hemodynamically stable, although continue melanic stools. HCT continued remain stable discharge. sent home sucralfate pantoprazole daily, along iron supplementation setting acute blood loss. #Hypovolemic shock- Patient presented hypotension elevated lactate resolved fluid resusciation blood products. Since EGD, remained hemodynamically stable, lactate trended down, required additional blood products. #Altered mental status- Patient found altered home intoxicated. positive flapping tremor started lactulose time transfer MICU. patient continued CIWA scale floor, required minimal diazepam symptoms. #Cirrhosis- Patient alcoholic/HepC cirrhosis. followed liver clinic Dr. [Last Name (STitle) ]. still actively drinking per postiive blood alcohol today ED. MELD score 15. thormbocytopenia known esophageal varices. history ascites hepatic encephalopathy, however flapping tremor somnolent time d/c MICU, persistent floor. treated 4d course ceftriaxone setting GI Bleed. #Alcohol abuse- Patient came MICU intoxicated >200 BAL. Social work consulted. patient demonstrated interest attending AA discharge. #Hypertension- Patient normotensive MICU admission, nadolol restarted transfer MICU continued floor. home lasix lisinopril held setting GI bleeding, signs fluid overload day discharge restarted. #hypokalemia - K around 3.3-3.5. Unknown etiology. repleted PO K. #Depression- Patient restarted citalopram able tolerate PO #Migraines- Fiorecet held hospital. patient full code throughout admission. TRANSITIONAL ISSUES: Pt need weekly labs follow hypokalemia hematocrit several weeks, f/u appt primary care [10-14]. f/u appointment GI need repeat EGD roughly 3 weeks per GI recommendations. Medications Admission: Preadmission medications listed correct complete. Information obtained webOMR. 1. Furosemide 20 mg PO DAILY Hold SBP<90 2. Spironolactone 50 mg PO DAILY Hold SBP<90 3. Nadolol 20 mg PO DAILY Hold SBP<90, HR<60 4. Acetaminophen-Caff-Butalbital [2-8] TAB PO Q8H:PRN headache 5. Citalopram 10 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Thiamine 100 mg PO DAILY Discharge Medications: 1. Nadolol 20 mg PO DAILY Hold SBP<90, HR<60 2. Acetaminophen-Caff-Butalbital [2-8] TAB PO Q8H:PRN headache 3. Citalopram 10 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) mouth daily Disp #31 Tablet Refills:3 8. Sucralfate 1 gm PO BID RX sucralfate 1 gram 1 tablet(s) mouth twice day Disp #31 Tablet Refills:4 9. Lactulose 30 mL PO TID RX lactulose [Constulose] 10 gram/15 mL 15-30 mL mouth use 4 times day Disp #1000 Milliliter Refills:3 10. Ferrous Sulfate 325 mg PO BID RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) mouth twice day Disp #62 Tablet Refills:3 Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: [Doctor First Name ]-[Doctor Last Name ] Tears Alcoholic intoxication Secondary: Hepatitis C Virus Cirrhosis Migraines Hypertension Chronic low back pain Lower extremity edema Depression Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], recently admitted [Hospital1 18] found altered mental status. here, EGD vomitting blood showed change varices, evidence tearing likely caused bleeding. changes home medications. imperitive discontinue drinking, likely cause hospital admission. pleasure take care patient here. Please hesitate contact us questions, comments concerns. Warm Regards, Inpatient Medicine Team Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2151-10-14] 2:10 PM With: Dr. [Last Name (STitle) ] [Name (STitle) ] Location: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] South [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage appointment hospital-based doctor part transition hospital back primary care provider. [Name10 (NameIs) 616] visit, see regular primary care doctor follow up. Department: LIVER CENTER When: FRIDAY [2151-10-22] 11:00 With: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: FRIDAY [2151-10-22] 9:00 With: ULTRASOUND [Telephone/Fax (1) 590] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "2851", "4019" ]
Admission Date: [2200-2-24] Discharge Date: [2200-3-4] Date Birth: [2123-2-5] Sex: F Service: CARDIOTHORACIC Allergies: Nitroglycerin / Penicillins / Amoxicillin / Norvasc / Celecoxib / Adhesive Tape / Lovenox Attending:[First Name3 (LF) 922] Chief Complaint: Exertional chest pain Major Surgical Invasive Procedure: [2200-2-25] - Coronary artery bypass grafting three vessels. (Saphenous vein graft->Diagonal artery, first obtuse marginal artery second obtuse marginal artery. [2200-2-24] - left heart Catheterization,coronary angiogram History Present Illness: 77 year old white female known coronary artery disease, undergone stenting LAD circumflex vessels past. presented recurrent angina elsewhere ruled non ST myocardial infaction Troponin 1.19. transferred underwent catheterization [2-25]. Catheterization revealed osteal circumflex subtotal stent circumflex stenosis. LV function shown ~55%. referred surgical revascularization. Past Medical History: hypertension hyperlipidemia noninsulin dependent Diabetes mellitus Moderate aortic stenosis Chronic atrial fibrillation Congestive heart failure past Coronary artery disease percutaneous interventions past Anxiety Cerbrovascular disease-60-70% bilateral carotid arteries H/O breast cancer, s/p right lumpectomy radiation H/O cervical cancer, s/p hysterectomy radiation appendectomy cholecystectomy H/O multinodular goiter S/P removal pylonidal cyst S/P bilateral carpal tunnel surgery S/P bone spur removal Osteoarthritis coccyx ulcer - stage IV Social History: patient currently lives alone. husband alzheimer's disease lives care facility. one son handicapped grandson. quit smoking 35 years ago; previously 4 ppd. drink alcohol use ilicit drugs. Family History: Family history negative premature coronary artery disease sudden death. Mother died complications alcoholism. Father died pneumonia. Grandmother died colon cancer. Physical Exam: Admission: VS - 97.3, 100/74, 16, 95%RA Gen: WDWN elderly female NAD. Oriented x3. Mood, affect appropriate. Patient lying supine post-cath. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. Neck: Supple without lymphadenopathy. CV: Irregularly irregular, normal S1, S2. [3-31] holosystolic murmur loudest LUSB radiates carotids. thrills, lifts. S3 S4. Chest: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. CTAB, crackles, wheezes rhonchi anteriorly. Abd: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. Ext: c/c/e. femoral bruits. Skin: Brown skin changes around left lower leg. stasis dermatitis, ulcers, scars, xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [2200-2-24] 04:45PM GLUCOSE-113* UREA N-11 CREAT-0.5 SODIUM-139 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 [2200-2-24] 04:45PM ALT(SGPT)-18 AST(SGOT)-36 CK(CPK)-166* ALK PHOS-58 AMYLASE-16 TOT BILI-0.8 [2200-2-24] 04:45PM cTropnT-0.22* [2200-2-24] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.7 [2200-2-24] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.7 [2200-2-24] 04:45PM PT-17.2* PTT-31.9 INR(PT)-1.6* [2200-2-24] Cardiac Catheterization 1. Coronary angiography right dominant system revealed three vessel coronary artery disease. LMCA angiographycally apparent coronary artery disease. LAD non-obstructed. D1 ostial 80% lesion. LCx subtotally occluded in-stent restenosis mid stent ostium vessel. RCA small caliber, 70% lesion proximally. 2. Resting hemodynamics revealed elevated left sided filling pressures LVEDP 20 mmHg. normal systemic arterial systolic diastolic pressure SBP 109 mmHg DBP 72 mmHg. 3. peak peak transaortic gradient 5 mmHg 4. Left ventriculography performed. [2200-2-25] ECHO left atrium mildly dilated. left atrium elongated. right atrium moderately dilated. estimated right atrial pressure 0-10mmHg. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%). right ventricular cavity mildly dilated normal free wall contractility. ascending aorta mildly dilated. aortic valve leaflets moderately thickened. mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild moderate ([12-27]+) mitral regurgitation seen. [Due acoustic shadowing, severity mitral regurgitation may significantly UNDERestimated.] tricuspid valve leaflets mildly thickened. Moderate severe [3+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. pericardial effusion. Compared prior study (images reviewed) [2199-10-19], severity mitral tricuspid regurgitation increased. Estimated pulmonary artery pressures higher. Aortic stenosis mild severity. [2200-3-2] 06:13AM BLOOD WBC-9.7 RBC-3.01* Hgb-9.6* Hct-27.8* MCV-93 MCH-32.0 MCHC-34.6 RDW-16.0* Plt Ct-121* [2200-3-3] 05:04AM BLOOD PT-20.6* INR(PT)-1.9* [2200-3-2] 06:13AM BLOOD PT-19.8* PTT-30.8 INR(PT)-1.9* [2200-3-1] 05:30PM BLOOD PT-22.3* INR(PT)-2.1* [2200-3-1] 03:45AM BLOOD PT-20.0* PTT-35.0 INR(PT)-1.9* [2200-2-28] 02:10AM BLOOD PT-16.6* PTT-32.6 INR(PT)-1.5* [2200-2-27] 12:58AM BLOOD PT-16.3* PTT-31.4 INR(PT)-1.5* [2200-2-26] 03:09PM BLOOD PT-17.8* PTT-40.7* INR(PT)-1.6* [2200-2-26] 01:55PM BLOOD PT-18.0* PTT-34.4 INR(PT)-1.6* [2200-2-26] 02:20AM BLOOD PT-17.0* PTT-53.2* INR(PT)-1.5* [2200-2-25] 05:19PM BLOOD PT-16.8* PTT-80.5* INR(PT)-1.5* [2200-2-25] 05:10AM BLOOD PT-18.5* PTT-59.1* INR(PT)-1.7* [2200-3-3] 05:04AM BLOOD UreaN-22* Creat-0.6 Na-129* K-4.0 Brief Hospital Course: Ms. [Known lastname 14330] admitted [Hospital1 18] [2200-2-24] cardiac catheterization management myocardial infarction. cardiac catheterization revealed two vessel disease severe instent restenosis circumflex artery. Given severity disease fact refused take plavix, surgical revascularization decided upon. Ms. [Known lastname 14330] worked-up usual preoperative manner including carotid ultrasound showed mild right moderate left internal carotid artery stenosis. Heparin continued remained without chest pain. wound care nurse [First Name (Titles) ] [Last Name (Titles) 4221] assistance coccyx ulcer appropriate dressings barrier creams applied. [2200-2-26], Ms. [Known lastname 14330] taken Operating Room underwent coronary artery bypass grafting three vessels. Please see operative note details. Postoperatively taken intensive care unit monitoring. next several hours, awoke neurologically intact extubated. Beta blockade, aspirin statin resumed. Diuresis towards preoperative weight begun. coccyx wound treated Aquacel AG daily. Surgical wounds clean dry. Pacing wires CTs removed according protocol. Bactroban administered MRSA positive nasal swab. Lopressor digoxin given advanced rate control chronic atrial fibrillation diuretics continued, achieves preoperative weight. STOP [3-3] Medications Admission: ativan 3 HS, atenolol 25, lipitor 80, ASA 325, digoxin 0.125, lisinopril 40, colace, coumadin 2.5, januvia 100, magnesium oxide 400, lasix 40 KCl 10 every day, MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) needed constipation. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 10. Digoxin 250 mcg Tablet Sig: [12-27] alter w/ 1 tab Tablet PO EVERY DAY (Every Day). 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once day (at bedtime)) needed insomnia. 12. Januvia 100 mg Tablet Sig: One (1) Tablet PO day. 13. Warfarin 1 mg Tablet Sig: dosed per INR Tablet PO DAILY (Daily): Goal INR [1-28] INR 2.6 [3-4]- coumadin given. 14. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection Q12H (every 12 hours). 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass Hyperlipidemia Hypertension Atrial fibrillation non insulin dependent Diabetes mellitus Anxiety s/p Myocardial infarction Peripheral vascular disease Cerebrovascular disease Multinodular goiter Osteoarthritis h/o Cervical cancer Discharge Condition: deconditioned Discharge Instructions: 1) Monitor wounds signs infection. include redness, drainage increased pain. event drainage sternal wound, please contact [Name2 (NI) 5059] ([Telephone/Fax (1) 1504]. 2) Report fever greater 100.5. 3) Report weight gain 2 pounds 24 hours 5 pounds 1 week. 4) lotions, creams powders incision healed. may shower wash incision. Gently pat wound dry. Please shower daily. bathing swimming 1 month. Use sunscreen incision exposed sun. 5) lifting greater 10 pounds 10 weeks date surgery. 6) driving 1 month taking narcotics pain. 7) Call questions concerns. Followup Instructions: Please follow-up Dr. [Last Name (STitle) 914] 1 month. ([Telephone/Fax (1) 1504] Please follow-up Dr. [Last Name (STitle) ] 2 weeks. [Telephone/Fax (1) 8725] Please follow-up Dr. [Last Name (STitle) 1057] [1-29] weeks. [Telephone/Fax (1) 14331] Please call appointments Completed by:[2200-3-4]	[ "4280", "4019", "2724" ]
Admission Date: [2103-5-19] Discharge Date: [2103-5-27] Date Birth: [2080-7-19] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid Attending:[First Name3 (LF) 1055] Chief Complaint: Back pain one day Major Surgical Invasive Procedure: None History Present Illness: Ms. [Known lastname 14164] 22 year-old African-American woman known [Known lastname 14165] cell disease, presents 1-day history right-sided posterior chest pain. notes well 4-days prior admission developed URI symptoms, including headache, rhinorrea, generalized fatigue. subsequently developed cough, productive small amounts dark yellow sputum. Yesterday, developed right-sided posterior chest pain, pleuritic nature, worse coughing, deep breathing lying culprit side. reports mild SOB. felt warm past days, measure temperature. denies chills. unsure whether received Pneumovax Influenza vaccines. ROS otherwise negative joint pain. GI urinary complaints. lightheadedness, dizziness. ED, vitals initially 99.4, HR 80, BP 119/58, RR 16, oxygen saturation 95% 3L, 88% room air. CXR revealed RLL infiltrate. given Ceftriaxone 1 gm IV X1 Azithromycin 500 mg PO QD. also given Morphine 1 mg IV X1, Benadryl 25 mg X1, Dilaudid pain control. Past Medical History: 1. [Known lastname ] cell disease, 1 admission per year since [2100] acute pain crisis. 2. History gonorrhea 3. Prior pneumonia versus acute chest syndrome [2100] 4. History pre-eclampsia first pregnancy 5. Known multiple RBC allo-antibodies difficult cross-match Social History: lives 2 children aged 4 2 years-old. active smoker, smokes 5 cigarettes per day. quit 3 years, restarted last year. EtOH consumption. also denies illicit drug use. Family History: lived [Doctor Last Name ] home age 5 onwards. Per OMR records, mother father [Name2 (NI) 14165] cell trait. children [Name2 (NI) 14165] cell trait. Physical Exam: Physical examination admission: VITALS: 99.4, HR 100, BP 110/55, RR 20, Sat 99% 3 liters via NC. GEN: Sleepy. Scratching over. Uncomfortable motion. HEENT: Anicteric. EOMI. PERRL. Frontal bossing. LN: cervical lymphadenopathy. RESP: Dullness percussion right base. Decreased air entry right base, basilar crackles. bronchial breathing. + egophony, + whispered pectoriloquy. CVS: PMI displaced. Normal S1, physiologic splitting S2. S3, S4. Soft, late systolic murmur apex, non-radiating. GI: BS NA. Abdomen soft non-tender. EXT: Strong pedal pulses. pedal edema. Pertinent Results: Relevant laboratory data admission: CBC: WBC 11.1, Hb 6.9, Hct 19.9, Platelet 552 NEUTS-54 BANDS-1 LYMPHS-35 MONOS-7 EOS-2 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1 HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-2+ [Name2 (NI) ]-2+ Chemistry: Na 138, K 4.7, Cl 106, HCO3 24, BUN 8, Creat 0.7, Glucose 0.7 Relevant imagind studies: [2103-5-19] CXR: Stable cardiac contours. Interval development patchy opacity right lower lobe, pleural effusion. [2103-5-20] CXR: Heart size within normal limits evidence CHF. consolidation right middle right lower lobes associated small right pleural effusion, increased compared prior film [5-19], 05. atelectasis left lung base previously demonstrated. probably associated collapse right lobe. IMPRESSION: Increase extent right middle lobe right lower lobe consolidation small right pleural effusion. Left basilar atelectasis. [2103-5-21] CXR: cardiac silhouette upper limits normal size slight increase pulmonary vascularity, consistent patient's known [Year/Month/Day 14165] cell status. multifocal areas consolidation involving right middle lower lobes, progressed interval. also bilateral probable small pleural effusions. IMPRESSION: Worsening multifocal consolidation suggesting multifocal pneumonia. [Year/Month/Day ] cell lung differential diagnosis infectious symptoms present. [2103-5-22] CXR: significant interval change. [2103-5-23] CXR: Increased mild moderate left pleural effusion. Persistent right middle lower lobe infiltrate right pleural effusion, stable. [2103-5-24] CXR: Slight interval improvement right middle lobe aeration. Slight improvement right pleural effusion. Stable left pleural effusion left lower lobe retrocardiac atelectasis. [2103-5-26] CXR: Improving right middle lobe left lower lobe opacities. small left-sided pleural effusion unchanged. ****** [2103-5-22] ECHO: left atrium mildly elongated. Left ventricular wall thickness, cavity size, systolic function normal (LVEF>55%). Regional left ventricular wall motion normal. Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve leaflets mildly thickened. mitral valve prolapse. trivial mitral regurgitatino. borderline pulmonary artery systolic hypertension. pericardial effusion. Brief Hospital Course: 22 year-old African-American woman [Year/Month/Day 14165] cell disease admitted respiratory symptoms right-sided back pain, found RLL infiltrate + hypoxemia. 1) Pneumonia +/- acute chest syndrome: CXR admission revealed RLL infiltrate suspicious pneumonia, although acute chest syndrome ruled out. Examination also remarkable hypoxemia, saturation low 80s. empirically started Ceftriaxone Azithromycin coverage Mycoplasma, Chlamydia, Hemophilus pneumococcus, hydrated. afebrile admission, subsequently developed fever hospital rising WBC 34.6 [5-21]. also developed worsening hypoxemia [5-21] increasing SOB setting decreasing hematocrit 15.5, 14.3. ABG revealed pH 7.41/38/70. repeat CXR performed remarkable worsening RML/RLL pneumonia. Given well inability transfuse PRBCs [3-21] available cross-matched blood (multiple allo-antibodies), Ms. [Known lastname 14164] transferred ICU [5-20]. ICU, supportive care provided. continued Ceftriaxone Azithromycin. Sputum cultures returned OP flora, without predominance organisms (can rule Chlamydia Mycoplasma). Blood urine cultures returned negative. Serial CXRs initially revealed worsening picture, interval development LLL infiltrate consistent multilobar process, bilateral pleural effusions. echo performed showed normal EF>60%. effusions ultimately felt likely [3-21] fluid overload setting aggressive IVF administration, diuresed Lasix [5-23] [5-24]. eventually improved defervesced, decreasing oxygen requirements improved radiographic picture. Antibiotics changed PO Levofloxacin [5-24], Ceftriaxone D/C'd [5-24] (received 6 days), Azithromycin D/C'd [5-25] (received 7 days). complete 14-day course (total) Levofloxacin (last dose [2103-6-1]). note, effusions persist discharge, stable size. also persistent leukocytosis WBC 16.2 discharge. improve time. need follow-up imaging completion antibiotic course document complete resolution infiltrate/effusion, well repeat WBC. effusions persist, thoracentesis would indicated rule parapneumonic effusion. given Pneumococcal, Meningococcal Hib vaccines prior discharge. follow-up PCP [Name Initial (PRE) 176] 1 week discharge. 2) [Name Initial (PRE) ] cell disease: Hematocrit admission 19.9 (around baseline), 15.3 [5-20] 2+ [Month/Year (2) 14165] cells peripheral smear, nadir 14.3 [5-21]. hematology service consulted. Ms. [Known lastname 14164] multiple allo-antibodies HRB absent rare except African-Americans. blood bank unable provide matched blood. transfused 1 unmatched unit [5-22] pre-medication Prednisone 60 mg PO QD, without response. transfusion therefore held. Per hematology, folate increased 5 mg PO QD. hematocrit slowly trended 22 discharge. note, ferritin sent rule concomitant iron deficiency, returned elevated 791. appropriate reticulocytosis 22% setting anemia. follow-up Dr. [Last Name (STitle) ] Hematology within 1 week discharge. Treatment hydroxyurea addressed. 3) Pain control: Pain control achieved Dilaudid IV prn pre-medication Benadryl. switched PO OxyContin 10 mg PO BID oxycodone breakthrough [5-26], fair pain control. Tylenol around clock Naproxen also added. discharged OxyContin/Oxycodone/Naproxen/Tylenol + bowel regimen. 4) Bacterial vaginosis: Ms. [Known lastname 14164] diagnosed bacterial vaginosis prior admission, treated Flagyl. completed 5-day course Flagyl hospital, resolution symptoms ([5-22] --> [5-26]). 5) Oral lesions: hospital, developed oral lesions suspicious oral HSV. started Valtrex 1 gm PO TID plan complete 3 days. complete course out-patient (last doses [2103-5-28*]). Medications Admission: Folate 2 mg PO QD Metronidazole (has taking intermittently bacterial vaginosis) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:150 Tablet(s)* Refills:1 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day: Please take Oxycontin. Disp:60 Capsule(s) Refills:0 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 5 days: Start [5-28], last dose [6-1]. Disp:5 Tablet(s) Refills:0 4. Valacyclovir HCl 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times day) needed HSV 3 doses: Please take 1 pill tonight, 1 pill tomorrow morning 1 pill tomorrow night. . Disp:6 Tablet(s) Refills:0 5. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:25 Tablet Sustained Release 12HR(s) Refills:0 6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 6 hours) needed pain. Disp:40 Tablet(s) Refills:0 7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) 7 days. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: [Month/Year (2) ] cell disease Anemia Pneumonia RBC antibodies Secondary diagnoses: Bacterial vaginosis Probable oral herpes simplex Discharge Condition: Patient discharged home stable condition. Saturation 94-96% room air. Hematocrit 22.5. Discharge Instructions: Please return hospital call PCP develop worsening respiratory symptoms, including increasing shortness breath, increasing cough. also return develop fever. Please continue take Levofloxacin daily, last dose [6-1]. treat pneumonia. Start [5-28]. Please note also increased folate 5 mg daily. Please take Oxycontin 10 mg twice daily pain control. also take oxycodone 5 mg needed every 4 6 hours breakthrough pain. Note given 3 vaccines (Haemophilus influenza, Pneumococcal, Meningococcal vaccines) Followup Instructions: Please call PCP (Dr. [Last Name (STitle) 14166] [Telephone/Fax (1) 14167] schedule appointment see within 1 week discharge. need repeat CXR next 2 weeks. Please call Dr.[Name (NI) 220] office (Hematology) [Telephone/Fax (1) 9645], schedule appointment see within 1-2 weeks discharge. Completed by:[2103-5-27]	[ "486" ]
Admission Date: [2151-1-31] Discharge Date: [2151-2-16] Date Birth: [2096-2-11] Sex: Service: MICU HISTORY PRESENT ILLNESS: patient 54 year old man admitted Intensive Care Unit [2151-1-31], [Hospital3 6265] evaluation hematemesis, melena abdominal mass. patient well Tuesday prior admission developed headache point took Vicodin developed nausea vomiting abdominal pain. Thursday evening prior admission, states passed floor bathroom fall secondary severe pain. states loss consciousness fifteen minutes. denies head trauma. Saturday prior admission, patient states retching blood. presented Emergency Department [Hospital3 3583] admitted found hematocrit 26.3, potassium 6.2, also acute renal failure. Abdominal CT indicated large peripancreatic mass. patient transferred [Hospital1 69] evaluation. transfer, white blood cell count 28, creatinine 3.4. PAST MEDICAL HISTORY: 1. History spontaneous pneumothorax. 2. History immune complex mediated glomerulonephritis. 3. History peptic ulcer disease, status post surgery. 4. Acute renal failure. MEDICATIONS ADMISSION: Vicodin p.r.n. ALLERGIES: patient states allergic Sulfa, Aspirin Naprosyn. SOCIAL HISTORY: patient works sales. twenty pack year history smoking. denies alcohol street drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: admission, patient's temperature 97.0, heart rate 107, respiratory rate 15, blood pressure 135/42, oxygen saturation 98% two liters. general, patient alert, acute distress. neck supple. Pulmonary examination indicated scant crackles bilaterally. Cardiovascular examination indicated regular rhythm, normal S1 S2, II/VI systolic murmur. abdomen distended decreased bowel sounds mild diffuse tenderness percussion. extremity examination, patient 2+ peripheral pulses edema. stool guaiac negative. LABORATORY DATA: Initial laboratory studies indicated white count 28.6, hematocrit 25.6, platelet count 404,000. Chem7 indicated blood urea nitrogen 43 creatinine 3.4. INR elevated 1.9. Liver function tests within normal limits. Electrocardiogram indicated normal sinus rhythm, rate 99 beats per minute, normal axis, normal intervals ischemic changes. HOSPITAL COURSE: patient admitted Intensive Care Unit. Nasogastric lavage performed indicated presence coffee ground emesis. evaluated gastroenterology service emergent endoscopy performed indicated presence hiatal hernia well compression second third part duodenum. biopsy taken compression site indicated chronic inactive duodenitis focal Brunner gland hyperplasia. also gastric mucocele metaplasia. CT abdomen indicated 10 6.0 centimeter soft tissue mass within mesentery pelvic rim well 10 16 centimeter mesenteric retroperitoneal hematoma displaying duodenum anteriorly compressing inferior vena cava. Significant mesenteric lymphadenopathy also noted. Renal surgery services consulted. recommendation surgery service, follow-up abdominal CT p.o. contrast completed indicated persistent intra-abdominal hematoma intra-abdominal mass. patient also noted increased liver function tests ALT 622, AST 649, normal total bilirubin alkaline phosphatase. patient's hematocrit continued drop, bleeding scan conducted indicated active bleeding abdomen clear source. patient therefore received angiogram indicated presence superior mesenteric artery aneurysm well active bleeding gastroduodenal artery embolized. patient also developed shortness breath following administration total fourteen units packed red blood cells Intensive Care Unit. Chest x-ray indicated presence congestive heart failure possible left sided infiltrate. patient started Lasix well Levaquin Flagyl. hepatitis panel sent negative. ANCA sent concern possible polyarteritis nodosa, however, study negative. patient also started total parenteral nutrition secondary expected ileus following embolization. Intensive Care Unit following embolization, transaminases trended downward, creatinine improved, hematocrit remained stable. patient develop transient episodic hypertension systolic pressure 200 requiring Labetalol drip, however, successfully weaned patient transitioned Labetalol tablets. unit, also developed bipedal scrotal edema, thought secondary volume overload setting multiple transfusions. Echocardiogram conducted hospital day number four indicated ejection fraction greater 55% 1+ tricuspid regurgitation. hospital day number six, patient transferred floor additional workup questionable abdominal mass. repeat [Location (un) 1131] patient's existing CAT scans, determined initially read mass first CT likely extension hematoma. Follow-up imaging four weeks recommended. first day floor, patient spiked temperature 101.3 degrees Fahrenheit. Repeat chest x-ray indicated worsening pulmonary infiltrates bilaterally. point, patient switched Ceftazidime Clindamycin treat possible nosocomial pneumonia. Sputum blood cultures sent negative. patient's pulmonary status improved significantly intravenous antibiotics. patient able tolerate p.o. intake, total parenteral nutrition discontinued. However, patient noted pain eating found small lesion site denture insertion site. patient able tolerate food pretreatment Viscous Lidocaine solution. Although patient's initial abdominal pain subsided, maintained Oxycontin control residual abdominal pain floor. patient's lower extremity edema decreased administration intravenous subsequently p.o. Lasix. hospital day number ten, patient noted increasing jaundice altered mental status. Liver function tests time indicated alkaline phosphatase 1091 total bilirubin 11.4. transaminases slightly elevated. right upper quadrant ultrasound performed indicated dilatation common bile duct well presence biliary sludge. intrahepatic biliary duct dilatation gallstones. Endoscopic retrograde cholangiopancreatography performed consultation gastroenterology service. study indicated fifteen millimeter common bile duct stented well stenosis distal bulb. patient's liver function tests, jaundice mental status improved following endoscopic retrograde cholangiopancreatography. patient follow-up endoscopic retrograde cholangiopancreatography three months stent removal. Although patient's mental status improve following endoscopic retrograde cholangiopancreatography, residual symptoms agitation paranoia prompted psychiatry consultation recommended low dose Haldol p.r.n. worsening symptoms. However, patient's mental status slowly returned baseline. patient evaluated physical therapy service found would benefit acute rehabilitation. time discharge summary, patient screened placement acute rehabilitation facility. DISCHARGE DIAGNOSES: 1. Superior mesenteric artery aneurysm. 2. Status post embolization gastroduodenal artery. 3. Biliary sludge. 4. Pneumonia. 5. Glomerulonephritis. 6. History peptic ulcer disease. 7. History pneumothorax. MEDICATIONS DISCHARGE: 1. Lasix 80 mg p.o. q.d. 2. Viscous Lidocaine 2% solution 15 ccs swish spit meals p.r.n. 3. Senna two tablets p.o. q.h.s. p.r.n. 4. Colace 100 mg p.o. b.i.d. 5. Boost t.i.d. meals. 6. Protonix 40 mg p.o. b.i.d. 7. Labetalol 200 mg p.o. q12hours. 8. Albuterol Atrovent MDI two puffs q4hours p.r.n. 9. Lipitor 10 mg p.o. q.d. 10. Nephrocaps 1 mg p.o. q.d. DISPOSITION: time dictation, patient screened placement acute rehabilitation facility. follow-up endoscopic retrograde cholangiopancreatography stent removal three months following discharge well follow-up abdominal CT scan three weeks following discharge. follow-up [Hospital ] Clinic. DISCHARGE DISPOSITION: Improved. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2151-2-15] 19:22 T: [2151-2-15] 19:42 JOB#: [Job Number 96120]	[ "486", "4280" ]
Admission Date: [2135-12-26] Discharge Date: [2136-1-3] Date Birth: [2080-2-9] Sex: Service: HISTORY PRESENT ILLNESS: Patient 55-year-old man multiple medical problems including insulin dependent diabetes secondary severe pancreatitis [2123], remote history Hodgkin's disease [2113] treated among things, radiation therapy left patient severe osteoporosis resulting compression fractures, history alcohol abuse, chronic opioids residual pain secondary pancreatitis, presented [12-26] delta MS. Per patient's lifetime partner, patient self increased dose opiate using approximately four patches Fentanyl increasing Seroquel dose 150 300 mg. presented ED [2135-12-26] increased weakness, tremor, disorientation x2 months, worse prior three days. ED, patient's temperature 98.4, blood pressure 136-145/60-70. heart rate 71-130. treated Ativan 7 mg thought alcohol withdrawal, increased patient's sedation subsequently systolic blood pressure decreased 88-97. Patient negative head CT. lumbar puncture attempted, successful. Patient started acyclovir, Vancomycin empiric meningitis coverage. patient's Chem-7 time significant glucose 354, anion gap 13, 15 ketones urine. results, ED started patient insulin drip. blood gas initially 7.23/55/46, decreased 7.16/56/260. patient minimally alert time. progressive somnolence. Patient started BiPAP 10 5, admitted MICU. PAST MEDICAL HISTORY: 1. COPD. 2. Diabetes mellitus insulin dependent secondary chronic pancreatitis. 3. Chronic alcohol induced pancreatitis status post debridement. 4. History alcohol abuse. 5. Osteoporosis. 6. CHF ejection fraction 40%. 7. Hodgkin's disease status post XRT, chemotherapy, splenectomy. 8. Hypothyroidism. 9. GERD. 10. Vocal cord paralysis. 11. Chronic pain multiple narcotics. 12. Anxiety depression. ALLERGIES: known drug allergies. SOCIAL HISTORY: Patient 40 pack year history tobacco. recent ethanol use. PHYSICAL EXAM: Temperature 98.5, blood pressure 104/64, heart rate 107. Cardiovascular: Patient 3/6 systolic murmur heard best left lower sternal border apex. Abdomen soft, nontender, nondistended, multiple surgical scars. Extremities: cyanosis, clubbing, edema. Pulses [12-30]+ bilaterally. Neurologic: patient responds commands, moving four extremities. HOSPITAL COURSE: patient admitted MICU management. [2135-12-27], intubated due increased somnolence hypoxia. [2135-12-28], EEG performed, read possibly consistent encephalitis. Patient seen Neuro team, recommended MRI LP. [2135-12-28], patient's temperature spiked 101.6. continued ampicillin, ceftriaxone, acyclovir possible meningitis. also started bicarb drip metabolic acidosis. patient initially treated Ativan narcotic withdrawal, D/C'd later started lower dose Fentanyl. [2135-12-29], patient transferred VICU. Analysis CSF fluid revealed 2 monocytes, 15 lymphocytes, 1 band. Gram stain negative PMNs, macrophages, bacteria. Culture negative. PCR Listeria HSV negative. Results patient's MRI [2135-12-28] revealed normal brain parenchyma. blood breakdown edema present. Overall impression MRI grossly normal, however, study limited patient motion. MICU, patient extubated. mental status continued improve. continued antibiotics treatment presumed community acquired pneumonia. noted eosinophilia, improved course hospitalization. transfused 1 unit blood transiently went pulmonary edema setting transfusion. resolved Lasix nebulizers. Acyclovir D/C'd patient's MRI lumbar puncture negative. patient transferred medical floor, alert oriented, able ambulate cane, tolerating good p.o. intake. seen Physical Therapy, felt would benefit rehabilitation stay. CONDITION DISCHARGE: Stable. DISCHARGE STATUS: [Hospital3 2558] [Hospital ] Hospital. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Insulin dependent diabetes. 3. History chronic alcoholic-induced pancreatitis. 4. Remote history alcohol abuse. 5. Severe osteoporosis. 6. Congestive heart failure ejection fraction 40%. 7. Hodgkin's disease. 8. Hypothyroidism. 9. Gastroesophageal reflux disease. 10. Vocal cord paralysis exacerbated recent intubation. 11. Chronic pain multiple narcotics. 12. Anxiety depression. MEDICATIONS DISCHARGE: 1. Lasix 20 mg p.o. q.d. 2. Pantoprazole 40 mg p.o. q.d. 3. Lisinopril 5 mg p.o. q.d. 4. Morphine sulfate 15 mg p.o. q.6h. prn. 5. Clindamycin 600 mg IV q.8h. 6. Ceftriaxone 1 gram IV q.24h. 7. Docusate 100 mg b.i.d. 8. Fentanyl patch 150 mcg/hour transdermal patch q.72h. 9. Quetiapine fumarate 100 mg p.o. q.h.s. 10. Insulin-sliding scale 7 units glargine bedtime. 11. Lorazepam 1-2 mg IV q.3-4h. prn. 12. Levothyroxine 125 mcg p.o. q.d. 13. Folic acid 1 mg p.o. q.d. 14. Multivitamin. 15. Pancrease four capsules p.o. t.i.d. meals. 16. Tylenol prn. 17. Vitamin D. 18. Citalopram 40 mg p.o. q.d. 19. Calcium 500 mg p.o. t.i.d. 20. Antibiotic therapy completed [2136-1-10]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8184], M.D. [MD Number(1) 8185] Dictated By:[Last Name (NamePattern1) 9725] MEDQUIST36 D: [2136-1-3] 10:42 T: [2136-1-3] 11:00 JOB#: [Job Number 108105]	[ "486", "4280" ]
Admission Date: [2165-4-29] Discharge Date: [2165-5-15] Service: MEDICINE Allergies: Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Chest pain, total body pain Major Surgical Invasive Procedure: None History Present Illness: [Age 90 ] y/o F PMHx CAD, CHF EF 40%, recent admission respiratory failure requiring intubation presents total body pain chest pain. patient's current symptoms began Saturday nausea. following day (one day prior admission), patient experienced aching throughout body, including back, chest, back head. morning, patient awoke sleep 6am due right index finger pain, erythema, swelling, calor spread rest body (back, chest, back head). Finger pain described stiff, sore, achy associated calor. Total body pain described sharp body aches generalized, lasted received Morphine ED. patient describes chest pain along total body pain, received SL Nitro x3 without relief. pain similar features prior anginal equivalent, experienced chest pain, shortness breath, upper back pain, current pain consists nausea without dyspnea lightheadedness. . ER, vitals T99.9 BP 156/61 P76 R18 PO2 100% 2L. Chest pain [7-18] arrival started nitro gtt without significant relief symptoms. However, symptoms resolved morphine, currently 0/10. EKG revealed sinus rhythm baseline LBBB acute EKG changes. received Morphine 500cc bolus en route EMS, received additional Morphine ED. . evaluation floor, pt asymptomatic complaining thirst. denies PND, reports 2 pillow orthopnea remained unchanged years. . . REVIEW SYSTEMS: denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. denies recent fevers, chills rigors. denies exertional buttock calf pain. Denies fevers/chills, night-sweats, abdominal pain, diarrhea, dysuria, rash. report (+) congestion/cough white sputum since hospitalization, helped albuterol. review systems negative. . Cardiac review systems notable absence chest pain, dyspnea exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope presyncope. Past Medical History: # Diabetes # Dyslipidemia # Hypertension # Coronary Disease - s/p NSTEMI [9-16] medically managed Cath s/p stent [3-20]. # Chronic systolic/diastolic congestive heart failure, recent EF>60% # Chronic renal failure, stage III CKD - Dr [Last Name (STitle) ] # Hypertension # Hyperlipidemia, intolerant statins # Type 2 diabetes, diet-controlled # GERD # Breast Cancer - diagnosed [2145], s/p lumpectomy [State 108] # s/p total abdominal hysterectomy [2094] fibroids # Cataracts Social History: lives home alone, family area. Social history significant absence current tobacco use, remote social tobacco use college. history alcohol abuse. home [Year (4 digits) 269] w tele reports daily PT. Presents rehab following multiple admissions. Family History: family history premature coronary artery disease sudden death. father hypertension. sister alive healthy 93. Physical Exam: admission VS: T=98.6 BP=146/70 HR=75 R=20 PO2 sat= 100% 2L GENERAL: WDWN NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP <9 cm. CARDIAC: RRR, normal S1, S2. GII systolic murmer LSB, gallops, rubs. S4 present LSB apex. thrills, lifts. LUNGS: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. Crackles bases b/l; egophany. wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. NABS. EXTREMITIES: c/c/e. SKIN: stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ discharge VS: 97.3, 120/47, 52, 18, 100%RA I/O: 120/350 today, [Telephone/Fax (1) 93520] yesterday GENERAL: AAOx3, pleasant elderly female NAD. Fatigued, interactive. HEENT: NCAT. Sclera anicteric. NECK: Supple JVP <9 cm sitting 90 degrees CARDIAC: RRR, normal S1, S2. S4 present LSB apex. LUNGS: mild kyphosis. Resp unlabored, accessory muscle use. soft crackles bibasilarly, breath sounds bases decreased ABDOMEN: Soft, NTND. HSM tenderness. NABS. EXTREMITIES: c/c/e. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: CXR ([4-29]): Two views compared bedside examination obtained 10 hours earlier, well previous examinations [4-16] [2165-4-19]. clearing findings CHF bilateral pleural effusions, residual rounded LV enlargement atherosclerotic change involving thoracic aorta. lungs appear hyperinflated, suggestive underlying obstructive disease; however, focal airspace opacity. diffuse osteopenia slight anterior wedging several thoracic vertebrae resultant slight kyphosis. acute abnormality thoracic skeleton. . CXR ([5-5]): 1. Worsening pulmonary edema increasing small pleural effusions. 2. Bilateral lower lobe airspace opacities, may due dependent areas pulmonary edema superimposed secondary process aspiration infectious pneumonia. Followup radiographs diuresis may helpful regard. . CXR ([5-6]) CHEST, AP: Mild interstitial edema slightly worsened. Mild cardiomegaly small bilateral pleural effusions unchanged. Bibasilar consolidation stable. cardiac silhouette normal. aorta calcified tortuous. IMPRESSION: Slightly increased vascular congestion. . SUPINE ABDOMEN ([5-6]) Limited study partially imaged left abdomen. Bowel gas pattern present nonobstructive air seen non-dilated loops small large bowel. free intraperitoneal air pneumatosis. cardiac silhouette moderately enlarged. questionable deep sulcus sign right hemithorax, right clinical setting, may represent pneumothorax. small opacification left lower lung. . CBC [2165-5-13] 05:15AM BLOOD WBC-8.3 RBC-3.41* Hgb-10.1* Hct-30.1* MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt Ct-402 [2165-5-12] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.5* Hct-30.3* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.9 Plt Ct-355 [2165-5-11] 06:10AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-28.7* MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369 [2165-5-10] 05:20AM BLOOD WBC-6.0 RBC-3.09* Hgb-9.1* Hct-27.1* MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt Ct-389 [2165-5-9] 05:30AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.1* Hct-27.2* MCV-86 MCH-28.9 MCHC-33.5 RDW-14.7 Plt Ct-341 [2165-5-8] 05:15AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1* Hct-26.5* MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286 [2165-5-7] 06:02AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.0* Hct-26.2* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-305 [2165-5-6] 12:48AM BLOOD WBC-7.4# RBC-3.03* Hgb-8.9* Hct-25.7* MCV-85 MCH-29.4 MCHC-34.7 RDW-14.8 Plt Ct-239 [2165-5-5] 04:10AM BLOOD WBC-4.5 RBC-2.71* Hgb-8.3* Hct-23.8* MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 Plt Ct-248 [2165-5-4] 07:30AM BLOOD WBC-4.9 RBC-3.01* Hgb-9.1* Hct-26.6* MCV-88 MCH-30.3 MCHC-34.3 RDW-15.0 Plt Ct-239 [2165-5-3] 05:05AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.4* Hct-27.2* MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242 [2165-5-2] 05:25AM BLOOD WBC-5.8 RBC-3.36* Hgb-10.1* Hct-29.2* MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-225 [2165-5-1] 07:30AM BLOOD WBC-8.6 RBC-3.31* Hgb-9.9* Hct-29.5* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245 [2165-4-30] 10:50AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.8* Hct-28.6* MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt Ct-215 [2165-4-30] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.3* Hct-29.9* MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245 [2165-4-29] 07:55AM BLOOD WBC-16.0# RBC-3.75 Hgb-11.3* Hct-32.3* MCV-86 MCH-30.0 MCHC-34.9 RDW-15.6* Plt Ct-269 Coags [2165-5-11] 06:10AM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1 [2165-5-10] 05:20AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0 [2165-5-9] 05:30AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0 [2165-5-8] 05:15AM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1 [2165-5-7] 06:02AM BLOOD PT-12.6 PTT-31.4 INR(PT)-1.1 [2165-5-6] 01:01AM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1 [2165-4-30] 07:25AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1 Chemistry [2165-5-13] 05:15AM BLOOD Glucose-117* UreaN-116* Creat-3.7* Na-131* K-3.5 Cl-78* HCO3-40* AnGap-17 [2165-5-12] 04:35AM BLOOD Glucose-121* UreaN-117* Creat-3.5* Na-131* K-3.7 Cl-78* HCO3-39* AnGap-18 [2165-5-11] 06:10AM BLOOD Glucose-131* UreaN-117* Creat-3.7* Na-130* K-3.8 Cl-79* HCO3-38* AnGap-17 [2165-5-10] 05:20AM BLOOD Glucose-118* UreaN-119* Creat-3.7* Na-130* K-4.0 Cl-79* HCO3-37* AnGap-18 [2165-5-9] 05:30AM BLOOD Glucose-109* UreaN-119* Creat-3.7* Na-129* K-3.2* Cl-79* HCO3-35* AnGap-18 [2165-5-8] 05:15AM BLOOD Glucose-111* UreaN-118* Creat-3.9* Na-128* K-3.4 Cl-77* HCO3-34* AnGap-20 [2165-5-7] 06:02AM BLOOD Glucose-115* UreaN-116* Creat-4.1* Na-125* K-3.3 Cl-76* HCO3-34* AnGap-18 [2165-5-6] 04:08PM BLOOD UreaN-112* Creat-4.2* Na-129* K-3.7 Cl-81* HCO3-32 AnGap-20 [2165-5-6] 12:48AM BLOOD Glucose-137* UreaN-108* Creat-4.4* Na-123* K-3.8 Cl-75* HCO3-29 AnGap-23* [2165-5-5] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3* Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19 [2165-5-4] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126* K-3.9 Cl-80* HCO3-29 AnGap-21* [2165-5-3] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125* K-4.2 Cl-81* HCO3-28 AnGap-20 [2165-5-5] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3* Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19 [2165-5-4] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126* K-3.9 Cl-80* HCO3-29 AnGap-21* [2165-5-3] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125* K-4.2 Cl-81* HCO3-28 AnGap-20 [2165-5-3] 05:05AM BLOOD Glucose-136* UreaN-91* Creat-3.6* Na-127* K-4.1 Cl-85* HCO3-29 AnGap-17 [2165-5-2] 05:25AM BLOOD Glucose-135* UreaN-84* Creat-3.1* Na-135 K-4.0 Cl-92* HCO3-28 AnGap-19 [2165-5-1] 07:30AM BLOOD Glucose-110* UreaN-82* Creat-3.0* Na-136 K-4.3 Cl-94* HCO3-32 AnGap-14 [2165-4-30] 10:50AM BLOOD Glucose-186* UreaN-81* Creat-2.9* Na-135 K-3.4 Cl-92* HCO3-32 AnGap-14 [2165-4-30] 07:25AM BLOOD Glucose-109* UreaN-81* Creat-2.9* Na-136 K-3.4 Cl-92* HCO3-32 AnGap-15 [2165-4-29] 07:55AM BLOOD Glucose-163* UreaN-84* Creat-2.9* Na-138 K-3.5 Cl-94* HCO3-30 AnGap-18 [2165-5-13] 05:15AM BLOOD Calcium-9.0 Phos-5.1* Mg-3.8* [2165-5-12] 04:35AM BLOOD Calcium-9.0 Phos-4.7* Mg-4.0* [2165-5-11] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-4.0* [2165-5-10] 05:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-4.0* [2165-5-9] 05:30AM BLOOD Calcium-8.8 Phos-5.3* Mg-3.8* [2165-5-8] 05:15AM BLOOD Calcium-8.6 Phos-5.4* Mg-4.0* [2165-5-7] 06:02AM BLOOD Calcium-9.2 Phos-6.5* Mg-4.1* [2165-5-6] 12:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-5.8* Mg-3.6* [2165-5-5] 04:10AM BLOOD Calcium-8.9 Phos-6.1* Mg-3.3* [2165-5-4] 07:30AM BLOOD Calcium-9.1 Phos-5.1* Mg-3.0* [2165-5-3] 05:05AM BLOOD Calcium-9.1 Phos-4.2 Mg-3.0* [2165-5-2] 05:25AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.7* [2165-5-1] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.9* [2165-4-30] 10:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6 [2165-4-30] 07:25AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5 [2165-4-29] 07:55AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.5 Cardiac Enzymes [2165-5-6] 12:48AM BLOOD CK(CPK)-17* [2165-5-5] 04:10AM BLOOD CK(CPK)-11* [2165-5-2] 05:25AM BLOOD CK(CPK)-16* [2165-5-1] 09:14PM BLOOD CK(CPK)-20* [2165-4-30] 07:25AM BLOOD CK(CPK)-17* [2165-4-30] 03:40AM BLOOD CK(CPK)-15* [2165-4-29] 03:05PM BLOOD CK(CPK)-19* [2165-4-29] 07:55AM BLOOD CK(CPK)-20* [2165-5-6] 12:48AM BLOOD CK-MB-NotDone cTropnT-0.20* [2165-5-5] 04:10AM BLOOD CK-MB-1 cTropnT-0.19* [2165-5-2] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.09* [2165-5-1] 09:14PM BLOOD CK-MB-NotDone cTropnT-0.07* [2165-4-30] 07:25AM BLOOD CK-MB-NotDone cTropnT-0.07* [2165-4-30] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.06* [2165-4-29] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[Numeric Identifier 93521]* [2165-4-29] 07:55AM BLOOD cTropnT-0.03* Brief Hospital Course: [Age 90 ]yoF CAD s/p stent mid-[Name (NI) ], PTCA jailed OM1, IVUS LMCA MLA presenting body pain chest pain. . # CORONARIES: Patient h/o prior stent [Name (NI) ] PTCA jailed OM1 presenting atypical chest pain concerning ACS. significant EKG changes light LBBB (by Sgarbossa criteria), CE's negative. patient continued Aspirin 162mg daily Clopidogrel 75 mg daily per outpatient regimen. . # PUMP/CHF: Patient history chronic systolic diastolic heart failure EF 40% [3-/2165], moderate (2+) MR, small secundum ASD left-to-right shunt across interatrial septum rest. appeared clinically fluid overloaded without hypoxia, BNP >45,000. Pt complex course medicine floor multiple episodes worsening resp status thought due flash pulm edema. Initially, symptoms responded lasix additional BP control. However, renal function slowly worsened decreasing response diuresis. Pt became progressively uremic confused [5-5] mild respiratory distress. transferred CCU [5-6] received 240mg Lasix IV bolus followed gtt. aggressively diuresed, per renal recs, started Lasix 80mg PO BID. good volume output lasix. Patient good volume status since, episodes flash pulmonary edema. fluctuating O2 requirements, times saturating well room air times requiring 2L O2. . # Chronic renal failure: Stage III CKD, followed Dr [Last Name (STitle) ]. Patient baseline Cr 1.5 [Month (only) 956] baseline increased 2.4. admission patient worsening renal function creatinine rising 2.9 4.3. unclear whether patient's increasing creatinine due dehydration vs volume overload - particularly given recurrent episodes flash pulmonary edema CXR showing evidence fluid overload. aggressively diuresed CCU volume status stable 80 mg PO lasix [Hospital1 ]. Patient family decided decline hemodialysis focus comfort measures. # Renal Artery Stenosis: Patient atrophic right kidney, left renal artery stenosis. likely reason difficult diurese reason flashes easily. originally planned renal artery stenting, procedure held unstable, requiring CCU transfer. Goals care discussed patient renal stenting tabled patient decided aggressive management focus comfort. . # Body Pain: Patient describes body pain since waking morning admission. Unclear etiology, likely viral symptoms vs non-specific findings [3-12] CHF exacerbation. Infectious workup negative. Leukocytosis resolved discharge. Patient 2 transient episodes chest pain admission reproducible palpation worse movement, likely musculoskeletal etiology, relieved 0.5 mg PO morphine. . # Right Finger Pain: Pt initially presented right index finger erythema, swelling, calor consistent gout; septic arthritis osteomyelitis less likely given fevers, effusion, nidus infection. Resolved without intervention. . # Hypertension: Patient's home antihypertensives initially continued, following CCU transfer recurrent flash pulmonary edema, changed amlodipine, carvedilol, furosemide, imdur. Following CCU admission stable SBP ranging 110s-130s. . # Hyperlipidemia: Pt intolerant statins, given statins discussion PCP [Last Name (NamePattern4) ]: goals patient's care. . # Type 2 diabetes: diet-controlled. Covered SSI in-house. . # GERD: Continued Famotidine 20 mg Tablet per outpatient regimen . # Goals care: patient made DNR/DNI CCU. Patient family decided starting hemodialysis, preference comfort directed care. prior discharge hospital, patient asked sign DNR/DNI form would continue DNR/DNI status transport nursing facility, refused sign. Patient repeatedly stated want resuscitated, however refused sign form. amenable daughter (HCP) signing DNR/DNI forms her, however daughter available prior discharge sign papers. daughter understands would able sign DNR/DNI papers nursing facility. nursing facility, patient's care focused comfort care. Medications Admission: 1. Senna 8.6 mg [Hospital1 ] 2. Famotidine 20 mg Tablet 3. Calcitriol 0.25 mcg Capsule PO QMOWEFR 4. Aspirin 162mg daily 5. Clopidogrel 75 mg daily 6. Cyanocobalamin 500 mcg daily 7. Hydralazine 10 mg q6hr 8. Isosorbide Mononitrate 20 mg [Hospital1 ] 9. Docusate Sodium 100 mg [Hospital1 ] 10. Felodipine 10 mg daily 11. Carvedilol 12.5 mg [Hospital1 ] 12. Furosemide 40 mg Tablet [Hospital1 ] 13. Iron (Ferrous Sulfate) 325 mg daily 14. Nitrostat 0.4 mg Tablet, Sublingual prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) needed chest pain: 3 tablets needed chest pain 5 minutes apart. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) needed shortness breath, wheezing. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES DAY MEALS). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day needed constipation. 16. Miralax 17 gram Powder Packet Sig: Seventeen (17) grams PO day needed constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed constipation. 20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every six (6) hours needed pain. Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Primary Diagnosis: Acute Chronic Systolic Diastolic Heart Failure Pulmonary Edema Left Renal Artery Stenosis Secondary Diagnosis: Hypertension Diabetes Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes Level Consciousness: Lethargic arousable Activity Status: Ambulatory - requires assistance aid (walker cane) Discharge Instructions: presented hospital body pain chest pain. EKG blood tests show evidence heart attack, found heart failure. hospital, frequent episodes shortness breath improved starting Lasix help remove fluid. admission, many discussions whether start dialysis. final decision dialysis started, instead pursue hospice care instead. discharged nursing facility help treating symptoms making comfortable. . medications changed, please take medications listed below: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) needed chest pain: 3 tablets needed chest pain 5 minutes apart. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) needed shortness breath, wheezing. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES DAY MEALS). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day needed constipation. 16. Miralax 17 gram Powder Packet Sig: Seventeen (17) grams PO day needed constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed constipation. 20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every six (6) hours needed pain. Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs. Followup Instructions: Please call schedule appointment see primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3029] ([Telephone/Fax (1) 250**]), needed.	[ "5849", "4280" ]
Admission Date: [2191-11-28] Discharge Date: [2191-12-21] Date Birth: [2114-4-22] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Heparin Agents Attending:[First Name3 (LF) 1283] Chief Complaint: Mrs. [Known lastname ] s/p CABG [2187], increasing SOB/DOE. underwent cardiac catheterization [11-24] showed patent LIMA-LAD, totally occluded SVG-OM ectatic SVG-PDA, aortic valve area 0.59cm2. admitted [Hospital 24356] hospital diuresis due elevated wedge pressure transferred [Hospital1 18] surgery Major Surgical Invasive Procedure: s/p redo sternotomy/CABGx1 SVG-PDA/AVR 21mm pericardial [12-7] History Present Illness: Mrs. [Known lastname ] s/p CABG [2187], increasing SOB/DOE. underwent cardiac catheterization [11-24] showed patent LIMA-LAD, totally occluded SVG-OM ectatic SVG-PDA, aortic valve area 0.59cm2. admitted [Hospital 24356] hospital diuresis due elevated wedge pressure transferred [Hospital1 18] surgery. Past Medical History: CAD s/p CABG [2187] aortic stenosis h/o breast CA s/p lumpectomy radiation therapy R breast carotid stenosis-bilateral 50-70% lesions DM-type 2 elevated cholesterol venous stasis Physical Exam: discharge physical exam: T:98.1 P63 atrial fibrillation BP:123/62 RR:18 RA:SpO2 95% RA weight:[12-21] 91.4kg Neurological exam:She awake, alert, oriented x3, non-focal. Cardiovascular exam: regular rate rhythm without rub murmur Respiratory:breath sounds clear without wheezes rales GI:positive bowel sounds, soft, obese, non-tender, non-distended, nausea Extremities:warm well perfused, bilateral lower extremeties mild erythema, chronic venous stasis changes plaques. warmth tenderness. Sternal incision clean dry, area proximal portion incision 2 areas scabbed skin tears. erythema drainage. veing harvest site knee clean, dry intact Pertinent Results: [2191-12-21] 05:58AM BLOOD WBC-8.4 RBC-4.27 Hgb-12.9 Hct-37.9 MCV-89 MCH-30.3 MCHC-34.1 RDW-15.7* Plt Ct-277 [2191-12-21] 05:58AM BLOOD Plt Ct-277 [2191-12-21] 05:58AM BLOOD PT-20.3* PTT-32.6 INR(PT)-2.6 [2191-12-21] 05:58AM BLOOD Glucose-66* UreaN-16 Creat-1.0 Na-138 K-4.2 Cl-95* HCO3-34* AnGap-13 Brief Hospital Course: Mrs. [Known lastname ] admitted [Hospital1 18] [11-28] pre-operative evaluation. started IV heparin coronary disease. taken operating room [12-2] induced general anesthesia. noted purulent drainage lower extremeties area venous stasis. surgery canceled transferred ICU allow awaken started antibiotics. vascular surgery infectious disease consult obtained patient underwent ultrasound studies LE show significant reflux arterial occlusion. antibiotics, erythema drainage improved continued Lasix edema improved patient taken operating room [12-7] redo sternotomy, CABGx1-SVG-PDA, AVR 21 mm pericardial valve. patient transferred ICU stable condition. weaned extubated mechanical ventilation [12-7] without difficulty. episodes nausea started Reglan antiemetic relief. chest tubes pacing wires removed without incident. started lo dose Lopressor tolerated well, escalating doses Lasix achieve adequate diuresis. transferred ICU regular floor POD#5. early morning POD 6, developed atrial fibrillation rate controlled. thrombocytopenia postoperatively heparin antibody test found positive. hematology consult obtained recommended started argatroban anticoagulation. started well Coumadin argatroban turned INR became therapeutic. underwent ultrasound R arm due swelling show venous clot obstruction. postoperative course, continued nauseaus, KUB showed lot stool aggressive bowel regime. time, PO intake poor. GI consult obtained recommended continue current therapy POD#13 nausea improving. POD#12 noted periods bradycardia atrial fibrillation decided discontinue Lopressor, pauses. Medications Admission: aspirin 325mg qd lisinopril 5mg qd insulin 70/30 18 units qam, 15units qpm lopressor 50mg qam 25mg qpm nitropaste lasix 80mg iv qd Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) needed constipation. 7. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed. 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed pain. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times day needed nausea. 16. Insulin 70/30 70-30 unit/mL Suspension Sig: Five (5) units Subcutaneous twice day. 17. Insulin Regular Human 300 unit/3 mL Syringe Sig: directed Subcutaneous four times day: BS 121-140 2units SC BS 141-160 3units SC BS 161-180 4units SC BS 181-200 5units SC BS 201-220 6units SC BS 221-240 7units SV . Discharge Disposition: Extended Care Facility: [Location (un) ] [Location (un) 701] Discharge Diagnosis: AS/CAD h/o CHF DM PVD s/p breast lumpectomy d/t CA s/p radiation R breast carotid stenosis 50-70% bilaterally s/p CABG [2187] s/p redo sternotomy/AVR/redo CABG bilateral LE venous stasis bilateral LE cellulitis post op atrial fibrillation post op urinary retention post op gastroparesis/ileus/constipation +heparin antibodies Discharge Condition: good Discharge Instructions: may take shower wash incisions mild soap water swim take bath 1 month drive 1 month lift anything heavier 10 pounds 1 month apply lotions, creams, ointments powders incisions Followup Instructions: follow Dr. [Last Name (STitle) ] 2 weeks follow [Doctor Last Name ] 2 weeks follow Dr. [Last Name (STitle) ] [3-31] weeks Completed by:[2191-12-21]	[ "4280", "2720" ]
Admission Date: [2162-10-10] Discharge Date: [2162-10-14] Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[First Name3 (LF) 2736] Chief Complaint: fall Major Surgical Invasive Procedure: Single lead [First Name8 (NamePattern2) ] [Hospital 923] Medical Identity ADx SR 5180 History Present Illness: Ms. [Known lastname ] [Age 90 ] yo female h/o dementia, hypertension, osteoporosis presented [Hospital1 43650] s/p fall [Hospital3 ]. found bathroom wet floor recall happened. initially complained left knee pain found left eye hematoma. denied head injury/LOC normal head imaging ED. Additionally unremarkable C/T/L spine, bilaterall knee xray, CXR ED. patient initially placed observation plan PT case managment see send back assissted living. However, ED around 8 became bradycarduc 30s, asystolic, pulseless. compressions delivered patient ROSC, shock delivered. 7 second pause went back sinus rhythm. patient unable describe felt, however back baseline mental status within 1-2 minutes. complaints recollection event. responded questions said felt "lousy", could provide details. note patient visited [Hospital1 18] ED mechanical fall [8-14] also admitted mechanical fall [2161-8-20]. recent previous admission [2162-6-20] E. Coli Septicemia likely secondary Cholangitis c/b pancreatitis resolved antibiotics conservative management. ED patient received ASA 300mg PR oxycodone. Prior transfer CCU patient hemodynamically stable VS 97.7, HR 68, BP 128/51, RR 20, 99% RA. arrival floor, patient reports bladder hurts since foley placed. denies pain. denies CP, SOB, palpitations, dizziness/lightheadedness. reports hosptial fell, provide details. REVIEW SYSTEMS: Postive achy joints frequency urination. Negative dysuria. review systems, denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. denies recent fevers, chills rigors. denies exertional buttock calf pain. review systems negative. Cardiac review systems notable absence chest pain, dyspnea exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope presyncope. Past Medical History: - Dementia - Hypertension - Arthritis - Sjogrens - Cataracts - h/o Bleeding ulcer - Narrow complex tachycardia: [1-29], reverted sinus, toprol. - L2-L3 compression fractures - Anterior abdominal wall fat-containing hernia right inguinal hernia - Osteoporosis - Spinal Stenosis Social History: Lives [Hospital3 ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] facility ambulates walker. cooking cleaning done her. help shower three times per week. Previously interior decorator, 3 children, widowed, family involved. Patient states daughter [Name (NI) ] daughter [Name (NI) 6607]. Reports grand-daughters visit frequently. -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: Mother/Father CAD. Physical Exam: Admission Exam: VS: T=98.1 BP=161/74 HR= 60 RR=18 O2 sat= 93-97% RA GENERAL: WDWN [Age 90 ] y/o female NAD. Oriented person, place, time (knows month, year). Hard hearing. Mood, affect appropriate. Pleasantly confused. HEENT: NC. Left eye hematoma bruising present. Sclera anicteric. PERRL, EOMI. sl dry mucous membranes. NECK: Supple flat neck veins. CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best Right upper sternal border radiating clavicles. thrills, lifts. S3 S4. LUNGS: Resp unlabored, accessory muscle use. CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. +BS EXTREMITIES: c/c/e. SKIN: Scattered bruises UE bilaterally. 5-8 mm slightly raised round lesions scattered upper LE bilaterally (posterior>anterior L>R). PULSES: DP pulses 2+ bilaterally Discharge Exam: 97.8, P 80, BP: 94-159/50-80, RR: 18, 94% RA GENERAL: WDWN [Age 90 ] y/o female NAD. Hard hearing. Mood, affect appropriate. HEENT: NC. Left eye hematoma bruising present. Sclera anicteric. PERRL, EOMI. sl dry mucous membranes. NECK: Supple flat neck veins. CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best Right upper sternal border radiating clavicles. thrills, lifts. S3 S4. LUNGS: Resp unlabored, accessory muscle use. CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. +BS EXTREMITIES: c/c/e. SKIN: Scattered bruises UE bilaterally. 5-8 mm slightly raised round lesions scattered upper LE bilaterally (posterior>anterior L>R). bruising left knee. PULSES: DP pulses 2+ bilaterally Pertinent Results: Admission Labs: [2162-10-10] 02:30AM BLOOD WBC-9.7 RBC-5.00 Hgb-13.7 Hct-41.6 MCV-83 MCH-27.3 MCHC-32.8 RDW-16.6* Plt Ct-517* [2162-10-10] 02:30AM BLOOD Neuts-66.0 Lymphs-21.4 Monos-10.5 Eos-1.3 Baso-0.7 [2162-10-10] 02:30AM BLOOD PT-9.4 PTT-20.4* INR(PT)-0.9 [2162-10-10] 02:30AM BLOOD Glucose-107* UreaN-12 Creat-0.5 Na-127* K-7.8* Cl-94* HCO3-26 AnGap-15 (hemolyzed specimen) [2162-10-10] 04:41PM BLOOD CK(CPK)-209* [2162-10-10] 04:41PM BLOOD CK(CPK)-209* [2162-10-10] 08:55AM BLOOD cTropnT-<0.01 [2162-10-10] 04:41PM BLOOD CK-MB-7 cTropnT-<0.01 [2162-10-10] 01:00PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2 [2162-10-10] 04:21AM BLOOD Na-132* K-4.2 Discharge labs [2162-10-14] 05:47AM BLOOD WBC-9.6 RBC-4.45 Hgb-12.4 Hct-37.4 MCV-84 MCH-27.9 MCHC-33.2 RDW-17.0* Plt Ct-518* [2162-10-14] 05:47AM BLOOD UreaN-14 Creat-0.7 Na-131* K-4.4 Cl-94* HCO3-25 AnGap-16 [2162-10-12] 08:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1 Images: CT Head [10-10]: 1. acute intracranial hemorrhage fractures. 2. New opacification left mastoid air cells middle ear cavity, please correlate signs infection. CT C-Spine [10-10]: acute cervical spine fracture. Multilevel moderate-to-severe degenerative changes cervical spine, worse C4-C5 level. CT L-Spine [10-10]: 1. new lumbar spine fracture. Stable compression L2 L3 vertebral bodies. 2. Multilevel severe degenerative changes lumbar spine, worse L3-L4 level moderate spinal canal stenosis. CT T-Spine [10-10]: acute thoracic spine fracture. Mild compression superior endplate T3 vertebral body, likely chronic. Bilateral Knee Xray [10-10]: 1. acute fracture. 2. Bilateral tricompartmental osteoarthritis, severe left mild right. CXR [10-10]: cardiomediastinal hilar contours normal. lung volumes low, crowding bronchovascular markings lung bases. Patchy right basilar opacity may reflect atelectasis, aspiration focal/early pneumonia. CXR [10-10] (post chest compressions): Cardiomediastinal contours normal appearance. Lungs clear except tiny calcified granuloma periphery right lower lobe. rib fractures identified, portable chest radiographs relatively insensitive detecting rib fractures, especially involving anterior ribs. visible pneumothorax pleural effusion. Echo: [2162-10-11] left atrium normal size. atrial septal defect seen 2D color Doppler. mild symmetric left ventricular hypertrophy. left ventricular cavity unusually small. Regional left ventricular wall motion normal. Left ventricular systolic function hyperdynamic (EF>75%). Doppler parameters consistent Grade (mild) left ventricular diastolic dysfunction. mild resting left ventricular outflow tract obstruction. normal free wall contractility. aortic valve leaflets (3) mildly thickened aortic stenosis present. valvular aortic stenosis. increased transaortic velocity likely related high cardiac output. Mild moderate ([12-21]+) aortic regurgitation seen. mitral valve leaflets moderately thickened. Trivial mitral regurgitation seen. left ventricular inflow pattern suggests impaired relaxation. tricuspid valve leaflets mildly thickened. estimated pulmonary artery systolic pressure normal. pericardial effusion. IMPRESSION: Mild symmetric LVH small LV cavity size hyperdynamic LV systolic function. Consequently mild left ventricular outflow tract gradient systole. aortic valve thickened opens reasonably well - high velocity due LVOT gradient. Mild moderate aortic regurgitation. Probable diastolic dysfunction. CXR [10-13] Single-lead pacemaker standard position, terminating right ventricle. acute cardiopulmonary disease. Brief Hospital Course: Ms. [Known lastname ] [Age 90 ] y/o female history dementia, hypertension, previous h/o narrow complex tachycardia known cardiac history presented [1-21] fall found symptomatic 7 second asystolic pause ED ROSC chest compressions, shock delivered. Active issues: # RHYTHM: Patient previous history narrow complex tachycardia metoprolol. 7 second asystolic pause ED. Patient mulitple falls recently, unclear whether mechanical secondary bradycardia conduction abnormality. Differential includes high vagal tone, sick sinus syndrome, junctional abnormality. Tropnoin negative x 2. Normal K+ Mg2+. Metoprolol held. Patient monitored telemetry XX. EP consulted followed patient. pacemaker implanted [10-12] concern arrhythmia cause recurrent falls. patient follow EP pacemaker interrogation discharge. started diltiazem 45 mg po QID control rate rhythm given family report "fuzziness" fatigue attributed beta-blocker. one day levofloxacin discharge prophylaxis infection. # s/p Fall: patient presented ED secondary fall. Patient multiple falls recently. Cause unclear, likely multifactorial given dementia, patient uses walker, found symptomatic 7 second asystolic pause. Patient negative head CT, C/T/L spine CT, bilateral knee xrays ED. Falls sound mostly mechanical talking family. PT consulted recommended rehab. # ? bladder pain increased frequency urination: UA neg nitrite, neg leuks. Patient mild leukocytosis, however CPR preformed likely stress reaction. last admission patient asymptomatic bacturia. Urine culture sent ED, grew proteus mirabilis sensitive ciprofloxacin levofloxacin. received dose ciprofloxacin continued levofloxacin prophylaxis pacemaker insertion. completed three day course UTI [10-14]. # Hypertension: patient reported hypertension, labile last admission. Home metoprolol held bradycardia asystole. BP monitored throughout stay stable 45mg diltiazem QID. Chronic issues: # Dementia: patient currently AAO x 3, however confused. Home donezepil continued. # Sjogren's: continued saline eye drops # Osteoporosis, compression fractures: continued calcium, vitamin D, weekly alendronate. Home oxycodone continued prn pain. Transitional: -will need pacemaker interrogated [12-21] weeks -titrate diltiazem dose target BP HR, change long-acting formulation stable dose Medications Admission: Preadmission Medication list accurate complete. 1. Donepezil 10 mg PO HS 2. Omeprazole 20 mg PO DAILY 3. Vitamin 1000 UNIT PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Artificial Tears Preserv. Free 1-2 DROP EYES HS:PRN dry eyes 6. Alendronate Sodium 70 mg PO QMON 7. Calcium Carbonate 600 mg PO DAILY 8. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain 9. Polyethylene Glycol 17 g PO TID 10. cranberry NF unknown Oral daily 11. Glucosamine Sulf-Chondroitin NF (glucosamine [Doctor First Name ] 2KCl-chondroit) 500-400 mg Oral daily 2 tabs daily Discharge Medications: 1. Alendronate Sodium 70 mg PO QMON 2. Artificial Tears Preserv. Free 1-2 DROP EYES HS:PRN dry eyes 3. Calcium Carbonate 600 mg PO DAILY 4. Donepezil 10 mg PO HS 5. Omeprazole 20 mg PO DAILY 6. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain 7. Vitamin 1000 UNIT PO DAILY 8. Glucosamine Sulf-Chondroitin NF (glucosamine [Doctor First Name ] 2KCl-chondroit) 500-400 mg Oral daily 2 tabs daily 9. cranberry NF 0 unknown ORAL DAILY 10. Levofloxacin 500 mg PO Q24H Duration: 1 Days Last day [10-15] 11. Diltiazem 45 mg PO QID 12. Polyethylene Glycol 17 g PO DAILY Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: Sinus arrest Urinary Tract Infection Discharge Condition: Mental Status: Confused - always. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: pleasure taking care [Hospital1 18]. fell home brought hospital. tests look serious injury negative. slow heart rate needed pacemaker. pacemaker placed [10-12] complications. urine sample showed urinary tract infection antibiotic one week. lifting 5 pounds left hand lift left arm head 6 weeks. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2162-10-18] 11:00 With: [First Name11 (Name Pattern1) 539] [Last Name (NamePattern4) 13861], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: FRIDAY [2163-4-22] 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14290], OD [Telephone/Fax (1) 253] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5990", "4019" ]
Admission Date: [2107-1-17] Discharge Date: [2107-2-12] Date Birth: [2042-4-4] Sex: F Service: MEDICINE Allergies: Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor Attending:[First Name3 (LF) 2932] Chief Complaint: SOB Major Surgical Invasive Procedure: None. History Present Illness: 64 yo woman w/ h/o recurrent PEs s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter, GIB anticoagulated, COPD, discharged [2107-1-12] treated new PE presented ED SOB productive cough. readmitted [2107-1-17] found multifocal pneumonia treated Levo/Flagyl Vanco. Cultures positive MRSA. Levo Flagyl continued suspected aspiration PNA. pt recovered quickly since admission back home O2 requirement. getting bridged anticoagulation Lovenox starting [1-18] preparation discharge. However, developed severe abdominal pain palpable mass L abdomen. CT showed new large hematoma muscles left anterior lateral lower abdominal pelvic wall, without intraperitoneal retroperitoneal extent, associated mass effect lower abdominal pelvic bowel loops. Surgery [Month/Year (2) 4221] suggested intervention, monitoring now. HCT dropped 6 points setting, remained hemodynamically stable tachycardia present throughout hospital stay (95-115). required total 5 units PRBC 4 units FFP transfusions transferred MICU monitoring. hematocrit since stable serial checks. . ROS: baseline left mid chest pain exertion currently bothering her. denies current chest pain, SOB, dysuria, increased urinary frequency. stable R knee pain. Past Medical History: 1. H/O Rheumatic Fever - age 8 -dx'ed last year rheumatic heart disease per pt (states ED diagnosed this) syndenham chorea 2. ?CHF per pt. although [12-13] Echo revealed low normal LVEF, mildly thickened aortic mitral valves mild MR [First Name (Titles) ] [Last Name (Titles) ]. 3. Orthostatic hypotension 4. Chest pain - nearly monthly visits ED negative ischemic w/u past 5. Duodenal/gastric ulcer 6. Seven miscarriages 7. Ulcerative colitis 8. Diverticulosis-s/p colostomy reversal colostomy-had Colonoscopy [1-12] showed diverticuli without e/o active bleed 8. Panic attacks x 15 yrs 9. Depression - several SA past 10. Schizoaffective disorder 11. h/o polysubstance abuse 12. Iron deficiency anemia (baseline unclear-high 20's 30's) 13. COPD 14. PE [7-13], c/b GIB anticoagulation, s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter. New PE [2107-1-2], anticoagulation Social History: Lives lodge house. homemaker help cleaning. gets meals wheels. limited funds. Smoked 2 PPD X 40 yrs, quit smoking 4 months ago. Former drinker, reports drinking two 6 packs per day 2 yrs; quit 27 yrs ago. Denies h/o illicits IVDA. H/O domestic violence. Family History: Daughter -40 - colitis. 6 siblings. One sister died, 35, ovarian CA. Brother, died 48, stroke. Sister, died 64 infection. Father died 65 MI. Mom "psychotic", died stroke 93 Physical Exam: VS: 97.6 HR 114, Bp 118/74 RR 20-30 Sats 98% 2L. Gen: NAD, pleasant HEENT: PEERLA, MMM. Neck: supple, LAD Lungs: moderate air movement, decreased breath sounds bases CV: RRR, S1S2 present, distant heart sounds, murmurs Abd: +BS, S/ND, + umbilical hernia, ulcer mid abdomen-reportedly chronic, unchanged, mildy errythematous base. secretions. Tenderness L abdomen, palpable mass unclear extension, guarding, rebound Back: CVA tenderness. Ext: 2+ RLE, 1+ edema LLE/ c/c/ 1+ DP Neuro: A&Ox3, CN II-XII intact. moving extremities. Pertinent Results: ADMISSION LABS: [2107-1-16] 08:40PM PT-87.9* PTT-41.3* INR(PT)-11.8* [2107-1-16] 08:40PM WBC-16.2# RBC-3.63 HGB-11.6* HCT-33.5* MCV-93 MCH-32.1* MCHC-34.7 RDW-14.0 [2107-1-16] 08:40PM NEUTS-90.5* BANDS-0 LYMPHS-4.7* MONOS-2.4 EOS-2.0 BASOS-0.5 [2107-1-16] 08:40PM GLUCOSE-127* UREA N-16 CREAT-1.0 SODIUM-136 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [2107-1-16] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2107-1-17] 12:47AM LACTATE-1.3 [2107-1-22] 03:07AM BLOOD WBC-7.5 RBC-2.85# Hgb-8.6# Hct-25.6* MCV-90 MCH-30.3 MCHC-33.6 RDW-14.4 Plt Ct-243 [2107-1-22] 03:07AM BLOOD PT-22.4* PTT-31.1 INR(PT)-2.2* [2107-1-22] 03:07AM BLOOD Glucose-105 UreaN-11 Creat-0.6 Na-141 K-4.0 Cl-102 HCO3-35* AnGap-8 [2107-1-22] 03:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1 [2107-1-23] 04:34PM BLOOD PEP-HYPOGAMMAG IgG-535* IgA-254 IgM-109 . CTA chest: 1. Interval development patchy areas consolidation mucous plugging, particularly right lower lobe, right upper mid lobes suggest new infectious process aspiration. 2. Resolution previously identified pulmonary embolism. 3. Extensive centrilobular paraseptal emphysematous change. 4. Fluid-attenuating structure adjacent right T11-12 neural foramen also unchanged could perineural cyst. . CT abdomen/pelvis: 1. New large hematoma muscles left anterior lateral lower abdominal pelvic wall, without intraperitoneal retroperitoneal extent, associated mass effect lower abdominal pelvic bowel loops. 2. Unchanged infectious inflammatory opacities right middle lower lobes. . [2107-2-1] IR Embolization: 1. Right inferior epigastric arteriogram demonstrates extravasation contrast successful embolization Gelfoam stagnation flow. 2. right internal mammary artery demonstrated areas active extravasation contrast. . [2107-2-3] CXR: irregular opacity right lower lobe concerning pneumonia. pleural effusions. pneumothorax. left subclavian catheter tip overlies mid SVC. Heart size normal. Mediastinal hilar contours normal. IMPRESSION: Opacity right lower lobe concerning pneumonia. . [2107-2-8] LENIS: Extensive occlusive thrombus demonstrated common femoral vein takeoff greater saphenous vein extending distally popliteal veins bilaterally. color flow, compressibility, waveforms demonstrated within areas thrombus. IMPRESSION: Extensive, completely occlusive, bilateral deep venous thrombi extending common femoral veins popliteal veins. . [2107-2-9] ECG: Sinus tachycardia, Normal ECG except rate Brief Hospital Course: 64F w/ h/o recurrent PE s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter, GIB anticoagulation, COPD, recently admitted new PE, readmitted multifocal PNA, developed large abdominal wall hematoma context enoxaparin injections. # Multifocal Pneumonia: admitted multifocal pneumonia. started levofloxacin vancomycin. completed 7 day course levofloxacin. MRSA found grow sputum continued 14 day course vancomycin. originally presented elevated WBC count left shift quickly resolved initiation antibiotics. productive cough improved well remained baseline home O2 2L. Approximately 4 days completion 14 day course Vancomycin, patient developed worsening cough, SOB, upper respiratory symptoms. repeat CXR showed evidence new consolidation RLL. patient started back Levofloxacin/Flagyl. Vancomycin added regimen blood cultures showed 2/4 bottles GPC clusters chains. Additionally, sputum culture grew GNRs. Levofloxacin discontinued Meropenem started concern Pseudomonas given patient's long hospital course. O2 sat remained stable 93-100% 2L nasal cannula (which baseline). given mucomyst inhaled nebulizers assist breaking thick sputum. GNRs sputum grew E. coli. sensitivity profile E. coli patient's allergy penicillin cephalosporins, patient continued Meropenem. GPCs found grow Coag negative Staph. Surveillance cultures growth coag negative staph thought likely contaminant. Vancomycin discontinued. continue 14 day course Meropenem discharged PICC complete course. . # Pulmonary embolism/DVTs: multiple PEs one even since placement TrapEase IVC filter. CT recent previous hospitalization revealed appropriate location filter CTA admission showed improvement clot. Admission labwork revealed INR 7.9. Coumadin thus held reversed FFP vitamin K given history GIB anticoagulation. interim, therapeutic lovenox injections initiated, within days starting, developed large abdominal wall hematoma near lovenox injection site. hematocrit stabilized, started heparin gtt coumadin overlap. [Last Name (NamePattern4) 9533] Coumadin INR 1.2, found large Hct drop CT scan abdomen showed new rectus hematoma. subsequently transferred MICU closer monitoring. decided second hematoma anticoagulation, risks anticoagulation outweigh benefits time anticoagulated. terms hypercoagulable workup, negative thus far hyperhomocysteinemia, Factor V Leiden antiphospholipid antibody. Malignancy workup included colonoscopy EGD well CEA, within normal limits. SPEP revealed hypogammaglobulinemia, otherwise unremarkable. hospital course, also began complain worsening lower extremity pain. LENIs obtained showed evidence extensive, completely occlusive, bilateral deep venous thrombi extending common femoral veins popliteal veins. Radiology felt clots likely acute subacute nature. setting, hematology/oncology saw patient consider risks vs benefits anticoagulation. Antithrombin III, prothrombin mutation, Lupus anticoagulation [Location (un) 1169] Venom Viper sent reevaluate reason hypercoagulability. hematology/oncology team still felt risks coagulation outweigh potential benefits given patient multiple bleeding episodes setting anticoagulation. # Abdominal wall hematoma: mentioned above, developed large left-sided abdominal wall hematoma Lovenox injection site caused significant hct drop (originally 28.1-->19.4). Despite drop, remained hemodynamically stable (has sinus tachycardia baseline prior bleed). received 3 units prbcs, 4 units FFP. hematocrit stabilized stable, restarted heparin gtt. Coumadin re-initiated heparin gtt continued awaiting INR become therapeutic. [Location (un) 9533] Coumadin INR 1.2, found another Hct drop (25.9-> 22.2) CT scan abdomen showed new right-sided rectus hematoma. subsequently transferred MICU closer monitoring. given 1 unit FFP 9 units PRBCs [Date range (1) 39125] hematocrit became stable bumped appropriately transfusion. decided second hematoma anticoagulation, risks anticoagulation outweigh benefits time anticoagulated. complained [6-16] abdominal pain movement maintained stable hematocrits. pain likely [3-11] large rectus hematoma resolve time. Hct remained stable anticoagulation discontinued. # Thoracic mass: CT chest abdomen revealed stable thoracic mass (stable x 3years) thought potentially consistent neural cyst. evaluated MRI given long term stability also metal hardware place s/p elbow surgery facial plates. followed imaging ensure remains unchanged future. # ? Zoster: Patient reports history "herpes" right buttock. stay, developed tingling, itchiness multiple small erythematous skin lesions right buttock S2, S3 dermatomal distribution. vesicles appreciated. treated acyclovir. # Candidal vaginitis: Treated fluconazole x 2 resolution symptoms. # H/o GI bleeding recent admission: Recent colonoscopy showed diverticulosis active signs bleeding. blood stools admission even anticoagulated. stools guiac-ed multiple times found guiac negative. # Constipation: constipated baseline requires daily scheduled bowel regimen maintian regularity. # Hyperlipidemia: Continued lipitor. # Depression/SAD: Continued Prozac, risperdone, wellbutrin, klonopin. # Ulcerative Colitis: Remains remission. continued mesalamine. # Orthostatic hypotension: remained asymptomatic even ambulating physical therapy. continued midodrine. Medications Admission: 1. Fluoxetine 30 mg daily 2. Risperidone 3 mg PO HS 3. Bupropion SR 150 mg [Hospital1 ] 5. Nicotine 7 mg/24 hr Patch 6. Hexavitamin daily 7. ascorbic acid 500 tab 1 [Hospital1 ] 8. Calcium Carbonate 500 tab [Hospital1 ] 9. Ferrous gluconate 325 PO daily 10. Atorvastatin 20 mg daily 11. Fluticasone Salmeterol 250/50 [Hospital1 ] 12. Midodrine 5 mg tab 1 TID 13. Tiotropium bromide capsule one cap /day 14. Mesalamine 1200 TID 15. Pantoprazole 40/ day 16. Albuterol nebs prn (tid generally) 17. docusate sodium 18. Warfarin 5 mg/day 19. Ipratropium nebs prn (tid generally) 20. clonazepam 1mg po tid Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times day). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk Device Sig: One (1) Disk Device Inhalation [Hospital1 ] (2 times day). 7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please take levofloxacin. 13. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) needed. Disp:100 Lozenge(s) Refills:0 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [2-8] Sprays Nasal QID (4 times day). Disp:QS bottle Refills:2 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times day) needed anxiety. Disp:20 Tablet(s) Refills:0 18. Saline Flush 0.9 % Syringe Sig: Three (3) ml Injection twice day 20 doses: prior vanco dose. Disp:20 syringe Refills:0 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice day. 20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times day) needed. 21. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times day) needed. 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed pain. 24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 26. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times day). 27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) needed wheezing. 28. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 29. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed pain. 30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) needed: PICC line. 31. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) 7 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: 1) Pulmonary Embolism history DVT IVC filter placement [2106-7-8] 2) Community Acquired Pneumonia 3) History GI Bleed (extensive) [2106-7-8] anticoagulated 4) Abdominal wall hematoma, acute blood loss anemia requiring 10 units PRBCs anticoagulated current pulmonary embolism 5) Noscomial Pneumonia GNR sputum, 6) Coagulopathy 7) Noscomial UTI E. coli - quinolone resistant 8) Vagnitis, attributed broad spectrum antibiotic usage 9) otitis externa 10) tachycardia 11) diarrhea 12) incidentally noted left renal cyst/mass NOS 13) Coagulase negative staphylococcal bacteremia 14) Rectus sheath hematoma setting anticoagulation . Secondary: 1) chronic orthostatic hypotension 2) recurrent otitis externa 3) ulcerative colitis remission 4) chronic obstructive pulmonary disease 5) depression 6) h/o schizoaffective disorder Discharge Condition: Stable. Discharge Instructions: Please take medications prescribed, please keep follow-up appointments. Please call primary care doctor, Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) ], return Emergency Department experience fevers, chills, worsening shortness breath, dizziness, lightheadedness, worsened chest pain, nausea, vomiting, diarrhea, blood stools symptoms concern you. . Please take medications prescribed follow primary care doctor [First Name (Titles) 3] [Last Name (Titles) 4030] below. Followup Instructions: need set followup appointment see Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) ] [2-8] weeks. Please call ([Telephone/Fax (1) 39126] set appointment. . following appointment scheduled prior hospitalization: Provider: [Name10 (NameIs) ] SURGERY CLINIC Phone:[Telephone/Fax (1) 4652] Date/Time:[2107-1-28] 1:00 *Follow CT scan ultrasound left kidney recommended well Urologic follow due incidentally noted left renal cyst/mass may malignant.*** [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2937] Completed by:[2107-2-12**]	[ "2851", "2724" ]
Admission Date: [2193-4-11] Discharge Date: [2193-4-16] Date Birth: [2121-3-15] Sex: Service: NEUROSURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1854] Chief Complaint: Elective Admission Mass resection Major Surgical Invasive Procedure: [4-11]: Right craniotomy mass resection History Present Illness: Patient 72M known neurosurgery service prior hospitalization AVM hemorrhage. time, incidental mass identified, presents electively resection said mass. Past Medical History: IVH/AVM bleed [10-3] h/o Lt temporal AVM, HTN, depression , BPH, UTI, seizure, bladder stone s/p VP shunt, cyberknife (AVM [11-3]), cysts removal skin, lithotripsy, extra-ventricular drain [10-3] Social History: resides home wife Family History: Non-contributory Physical Exam: Discharge: patient oriented x 3. pupils 2mm bilaterally. EOMs intact. Face symmetric. Tongue midline. Left pronator drift. LUE weak well IP LLE. right side full strength. dressing removed staples clean, dry, intact. Pertinent Results: Labs Admission: [2193-4-11] 02:46PM BLOOD WBC-18.4# RBC-3.81 Hgb-11.0* Hct-32.7* MCV-86 MCH-28.8 MCHC-33.5 RDW-15.5 Plt Ct-517* [2193-4-12] 03:11AM BLOOD PT-12.8 PTT-24.1 INR(PT)-1.1 [2193-4-11] 02:46PM BLOOD Glucose-179* UreaN-11 Creat-0.7 Na-139 K-4.2 Cl-107 HCO3-24 AnGap-12 [2193-4-11] 02:46PM BLOOD Calcium-8.3* Phos-4.2 Mg-1.7 Imaging: MRI/A Head Neck [4-13]: TECHNIQUE: T1 sagittal axial FLAIR T2 susceptibility diffusion axial images brain acquired gadolinium. T1 axial MP- RAGE sagittal images obtained following gadolinium. 3D time-of-flight MRA circle [Location (un) 431] obtained. Gadolinium-enhanced MRA neck fat-suppressed axial images neck acquired. FINDINGS: BRAIN MRI: Comparison made previous MRI [2193-4-11]. Since previous study, patient undergone resection large meningioma right frontal region. Extensive right-sided brain edema identified. blood products surgical site. Although residual nodular enhancement seen, enhancement seen along sulci meningeal enhancement identified region. findings indicate pachy leptomeningeal enhancement. Mild slow diffusion surrounding area diffusion images indicative postoperative change. blood left lateral ventricle. persistent mass effect right lateral ventricle. Changes small vessel disease seen. left frontal drainage catheter identified. Note made new areas slow diffusion right medial thalamus. findings indicative acute infarcts new since previous study. noted enhancing meningioma tuberculum sella region. Additionally, enhancement flow void left medial temporal lobe region indicative aneurysm site previously noted arteriovenous malformation. Post-craniectomy changes seen right frontal region. Pneumocephalus identified. IMPRESSION: Previous MRI examination, patient undergone resection large frontal meningioma blood products surgical site without residual nodular enhancement. Leptomeningeal pachymeningeal enhancement seen appears postoperative. Acute right-sided thalamic infarcts seen new since previous study. findings stable described above. MRA NECK: neck MRA demonstrates normal flow carotid vertebral arteries. fat-suppressed images demonstrate subtle increased soft tissues adjacent proximal right common carotid artery seen CTA. could related small amount blood surrounding soft tissues recent attempted central venous line placement. definite dissection seen. IMPRESSION: Normal MRA neck. MRA HEAD: head MRA demonstrates evidence vascular occlusion stenosis. previously seen aneurysm relation left posterior cerebral artery apparent MRA. left medial temporal lobe arteriovenous malformation also clearly visualized. IMPRESSION: vascular occlusion stenosis seen MRA head. Postoperative changes noted following removal frontal lobe tumor. Acute right thalamic infarcts identified. MRA neck normal without dissection. MRA head demonstrates stenosis occlusion. Brief Hospital Course: Patient electively admitted [4-11] undergo resection brain mass. Post-operatively, transferred ICU continuous monitoring. perioperative course, central line placement complicated access carotid artery. Post-op, vascular surgery consulted, duplex studies performed, determined without injury carotid artery. MRI/A also done confirm well evaluate surgical resection. vascular surgery team agreed carotid artery dissection intervention needed part. patient extubated ICU transferred floor. well weekend. patient able eat without difficulty. PT OT evaluated recommended rehab placement. [4-16] patient noted bloody urine foley. urinalysis revealed UTI. started 14-day course cipro. patient sent rehab [4-16]. Medications Admission: APAP, Celexa 20mg', Compazine 20mg prn, Flomax 0.4mg', Folic Acid 1mg', Keppra 500mg", lactulose prn,Ativan 1mg prn, Metoprolol 50mg"', [Name (NI) 10687], MOM, Ritalin 20mg', Seroquel 25mg"', Trazadone 50mg hs Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed. 2. [Name (NI) 10687] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed. 10. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 14 days. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 15. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Right Frontal Meningioma Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? friend/family member check incision daily signs infection. ?????? Take pain medicine prescribed. ?????? Exercise limited walking; lifting, straining, excessive bending. ?????? may wash hair staples removed. ?????? may shower time using shower cap cover head. ?????? Increase intake fluids fiber, narcotic pain medicine cause constipation. generally recommend taking counter stool softener, Docusate (Colace) taking narcotic pain medication. ?????? Unless directed doctor, take anti-inflammatory medicines Motrin, Aspirin, Advil, Ibuprofen etc. ?????? discharged Keppra (Levetiracetam), require blood work monitoring. ?????? Clearance drive return work addressed post-operative office visit. ?????? Make sure continue use incentive spirometer home. CALL SURGEON IMMEDIATELY EXPERIENCE FOLLOWING ?????? New onset tremors seizures. ?????? confusion change mental status. ?????? numbness, tingling, weakness extremities. ?????? Pain headache continually increasing, relieved pain medication. ?????? signs infection wound site: increasing redness, increased swelling, increased tenderness, drainage. ?????? Fever greater equal 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return office [4-26] 10:00 removal staples wound check [Telephone/Fax (1) 1669]. ??????You need appointment Brain [Hospital 341] Clinic. call appointment. Brain [Hospital 341] Clinic located [Hospital Ward Name 516] [Hospital1 18], [Hospital Ward Name 23] Building. phone number [Telephone/Fax (1) 1844]. Please call need change appointment, require additional directions. ??????You need MRI brain done acute hospitalization. Completed by:[2193-4-16]	[ "5990", "4019" ]
Admission Date: [2146-11-17] Discharge Date: [2146-11-25] Service: NEUROLOGY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 8747] Chief Complaint: Left sided weakness Major Surgical Invasive Procedure: None History Present Illness: Mr. [Known lastname 65376] 83 yo RHM USOH afternoon sudden-onset left-sided weakness led falling ground. managed couple bystanders help get back motor scooter drive home. went apartment tried go bathroom. fell toilet found could get toilet called neighbor. [Name (NI) ] denies head trauma, HA, N/V, vertigo. ambulance brought [Hospital3 1443] Hospital head CT revealed right thalamocapsular hemorrhage transferred [Hospital1 18] management. sister reported recent weight loss. f/c/s/n/v/d, changes voice, difficulty swallowing, hearing, dizziness, vertigo, diplopia, blurry vision, headache, head trauma. Past Medical History: Inguinal hernia ORIF hip fx History MVA dragged car 70 years ago Social History: Lives alone, previously able care himself. Unmarried. intermittent contact two sisters daughter. Denies smoking, drugs, EtOH use. Family History: neurological disease. CA. Mother diabetes died CHF complication parathyroid abnormality. Father died 87 accident. Brother recently admitted [Hospital1 18] traumatic intracranial bleed. Physical Exam: PE: Gen, thin HEENT AT/NC, MMM lesions, bruits Neck Supple, thyromegaly, [Doctor First Name ], bruits Chest Clear, slightly decreased BS right base CVS RRR w/o MGR ABD soft, NTND, + BS, large left sided inguinal hernia. EXT C/C/E. petechiae, asterixis, rash penis, much lower extremities. Severe nail disease. Neuro MS: AA&Ox3, appropriately interactive, normal affect, normal fund knowledge [Doctor Last Name 1841] errors, simple calculations intact, fluent without paraphrasic errors. Prosody slow flat. Naming, [Location (un) 1131], intact. 0/3 5 minutes,[3-3] prompting L/R confusion. Normal graphesthesia. Able mimic brushing teeth either hand. CN: I--not tested; II,III-PERRLA, VFF confrontation, optic discs sharp normal vasculature; III,IV,VI-EOMI w/o nystagmus, ptosis; V--sensation intact LT/PP, masseters strong symmetrically; VII-Left facial weakness sparing forehead; VIII-hears finger rub bilaterally; IX,X--voice normal, palate elevates symmetrically, uvula midline, gag intact; [Doctor First Name 81]--SCM/trapezii [5-5]; XII--tongue protrudes midline, slight apraxia Motor: Normal bulk tone. rigidity, tremor, bradykinesia Strength: Left sided hemiplegia. Coord: FFM slow LEFT accurate. Refl: [Hospital1 ] Tri Brachio Pat [Doctor First Name ] Toe R 2 2 2 2 2 L 2 2 2 2 2 [Last Name (un) ]: LT, PP, temperature, vibration, position sense intact. evidence extinction. Pertinent Results: [2146-11-25] 11:25AM BLOOD WBC-9.3 RBC-3.86* Hgb-12.5* Hct-36.0* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.6 Plt Ct-180# [2146-11-24] 05:15AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.9* Hct-34.9* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.5 Plt Ct-115* [2146-11-23] 05:50AM BLOOD WBC-6.9 RBC-3.79* Hgb-12.3* Hct-35.3* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.7 Plt Ct-85* [2146-11-22] 10:40AM BLOOD WBC-11.2* RBC-3.98* Hgb-12.7* Hct-35.8* MCV-90 MCH-31.9 MCHC-35.5* RDW-14.0 Plt Ct-77* [2146-11-22] 05:15AM BLOOD WBC-14.5* RBC-3.79# Hgb-12.0# Hct-34.3# MCV-91 MCH-31.6 MCHC-34.9 RDW-14.2 Plt Ct-67 [2146-11-21] 01:57AM BLOOD WBC-15.4* RBC-2.91* Hgb-9.4* Hct-26.5* MCV-91 MCH-32.3* MCHC-35.5* RDW-13.9 Plt Ct-65* [2146-11-20] 03:00AM BLOOD WBC-19.6* RBC-2.98* Hgb-9.8* Hct-28.1* MCV-94 MCH-32.8* MCHC-34.8 RDW-13.4 Plt Ct-70* [2146-11-19] 02:30AM BLOOD WBC-25.1# RBC-3.44 Hgb-11.2* Hct-32.3* MCV-94 MCH-32.6* MCHC-34.7 RDW-13.4 Plt Ct-106* [2146-11-18] 04:58AM BLOOD WBC-5.7 RBC-3.66* Hgb-12.4* Hct-34.2* MCV-93 MCH-33.9* MCHC-36.3* RDW-12.9 Plt Ct-118* [2146-11-17] 07:30PM BLOOD WBC-6.7 RBC-3.78* Hgb-12.4* Hct-34.0* MCV-90 MCH-32.7* MCHC-36.4* RDW-13.1 Plt Ct-117* [2146-11-25] 11:25AM BLOOD Plt Ct-180# [2146-11-25] 11:25AM BLOOD Glucose-110* UreaN-23* Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-27 AnGap-12 [2146-11-24] 05:15AM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-139 K-4.4 Cl-106 HCO3-26 AnGap-11 [2146-11-23] 05:50AM BLOOD Amylase-53 [2146-11-22] 10:40AM BLOOD ALT-102* AST-52* Amylase-56 TotBili-0.6 [2146-11-19] 02:30AM BLOOD CK(CPK)-1600* [2146-11-21] 01:57AM BLOOD CK(CPK)-120 [2146-11-25] 11:25AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 [2146-11-18] 04:58AM BLOOD VitB12-786 [2146-11-18] 04:58AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [2146-11-18] 04:58AM BLOOD Triglyc-40 HDL-98 CHOL/HD-2.1 LDLcalc-98 [2146-11-22] 10:40AM BLOOD Ammonia-20 [2146-11-18] 04:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Barbitr-NEG Tricycl-NEG Urine Culture KLEBSIELLA PNEUMONIAE \| ENTEROBACTERIACEAE \| \| KLEBSIELLA PNEUMONIAE \| \| \| AMPICILLIN/SULBACTAM-- 4 4 <=2 CEFAZOLIN------------- <=4 <=4 <=4 CEFEPIME-------------- <=1 <=1 <=1 CEFTAZIDIME----------- <=1 <=1 <=1 CEFTRIAXONE----------- <=1 <=1 <=1 CEFUROXIME------------ 2 2 <=1 GENTAMICIN------------ <=1 <=1 <=1 IMIPENEM-------------- <=1 2 <=1 LEVOFLOXACIN----------<=0.25 <=0.25 <=0.25 MEROPENEM-------------<=0.25 <=0.25 <=0.25 NITROFURANTOIN-------- 32 =>512 R <=16 PIPERACILLIN/TAZO----- <=4 <=4 <=4 TOBRAMYCIN------------ <=1 <=1 <=1 TRIMETHOPRIM/SULFA---- <=1 <=1 <=1 Blood culture [11-18] KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 4 CEFAZOLIN------------- <=4 CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CEFUROXIME------------ 2 GENTAMICIN------------ <=1 IMIPENEM-------------- <=1 LEVOFLOXACIN----------<=0.25 MEROPENEM-------------<=0.25 PIPERACILLIN/TAZO----- <=4 TOBRAMYCIN------------ <=1 Repeat Urine culture <10,000 colonies Repeat Blood cultures negative three days. Head CT [11-17]:Right basal ganglia 21 x 10 mm intraparenchymal hemorrhage mild surrounding edema. prior studies available comparison. Head CT [11-18]: stable hemorrhage MRI/MRA: MRI demonstrates right thalamic hemorrhage, visualized CT scan [2146-11-17]. additional areas susceptibility artifact detected. signs acute infarction. MRA demonstrates flow major branches circle [Location (un) 431] abnormal vascularity. LEFT X-ray Knee Hip: fracture, dislocation, evidence hardware loosening. CXR:A feeding tube withdrawn slightly interval. Although tip still terminates stomach, proximal portion radiodense tip likely GE junction level. Cardiac silhouette stable size demonstrates left ventricular configuration. interval marked improved aeration left retrocardiac region minimal residual atelectasis remaining. Bilateral pleural effusions improved, resolved right nearly resolved left. new worsening areas opacification suggest pneumonia. Echo/TTE:The left atrium mildly dilated. patent foramen ovale small atrial septal defect could excluded color Doppler study. Left ventricular wall thicknesses normal. left ventricular cavity size normal. mild regional left ventricular systolic dysfunction probable distal septal hypokinesis. Overall left ventricular systolic function borderline depressed. [Intrinsic left ventricular systolic function may depressed given severity valvular regurgitation.] Right ventricular chamber size free wall motion normal. aortic valve leaflets mildly thickened. Mild (1+) aortic regurgitation seen. mitral valve leaflets mildly thickened. Moderate (2+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. trivial/physiologic pericardial effusion. cardiac source embolus identifed. Brief Hospital Course: Neurology - Mr. [Known lastname 65376] admitted ICU monitoring discovered left-sided secondary right sided thalmocapsular hemorrhage. ICU, remained hemodynamically stable however neurological exam worsened left sided hemiparesis essentially, hemiplegia involving left side, including face, arm, leg. differential included hypertensive hemorrhage, mass, aneurysm, hemorrhagic conversion embolic. patient little recorded reportable medical history unclear history HTN, clearly likely diagnosis mass observed MRA negtive vascular malformation. quite hypertensive admission, BPs 200/100s requiring IV hydralazine control. patient deterioration mental status transfer ICU. encephalopathy work-up revealed bilateral pleural effusions thought secondary possible aspiration pneumonia. antibiotic regimen changed Levofloxacin Metronidazole became alert oriented within 24 hrs. complete another 6 days Levofloxacin Flagyl. Physical therapy involved care moved bed chair. HbA1C, Lipids normal. Trans-thoracic Echocardiogram revealed normal EF without vegetations. Respiratory - pt intermittently required oxygen NC. diagnosed bilateral pleural effusions possible left sided pneumonia repeat CXR [11-25] showed interval resolution. currently oxygen requirement. FEN/GI - patient difficulty swallowing maintained NGT adequate fluid nutritional intake. Speech swallow recommended: 1. Continue NG tube feedings maintain nutrition/hydration 2. PO diet consistency nectar thick liquids purees SNACK 3. Basic aspiration precautions followed: a. Pt awake alert eating b. Pt seated upright bed meals. likely benefit f/u nutrionist Rehab. Pt. also large left inguinal hernia. [Last Name 19390] problem presented acute issues him. Renal/GU - Patient admitted hyophosphatemia hypomagnesemia responded well oral IV supplementation. recent Mg Phos normalized. [Doctor First Name ] kept Neuta Phos packets [Hospital1 ]. Patient evaluated Urology service difficulty Foley catheter placement ICU. catheter placed GU; recommended voiding trial [11-25] catheter pulled patient voided spontaneously. patient microscopic hematuria GU made aware this. recommendation could followed outpatient. ID - patient Klebsiella pneumoniae urosepsis. initially placed Gentamicin. subsequently drop platelets. bacteria also sensitive ceftriaxone switched concern thrombocytopenia (low 65) secondary gentamicin. gent discontinued, platelets subsequently recovered normal range. treated Levaquin IV Flagyl 2 days complete another 6 days two antibiotics Klebsiella pneumonia. HEME - Thrombocytopenia mentioned above. Pt. developed anemia tranfussed two units PRBCs ICU. since stable CBCs. anemia likely secondary acute illness. placed Heparin 5000 U SC DVT prophylaxis. Musculoskeletal: Pt c/o pain left knee. underwent X-rays knee left hip earlier hospitalization presented fall. tests negative fracture change hardware (secondary left hip ORIF past). PODIATRY - patient severe nail fungus Podiatry debrided nails. receiveing LacHydrin moisturizing cream feet severe dryness. much improvement hospital course. DISPO - Patient PCP would definitely benefit regular medical follow-up. phone number [Hospital ] provided. patient f/u appointments Urology Neurology/Stroke. Patient require long-term assistance ADLs benefit inpatient rehabilitation. DIAGNOSIS: Right thalamocapsular hemorrhage likely secondary hypertension Medications Admission: None Discharge Medications: 1. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: One (1) Packet PO BID (2 times day). Disp:60 Packet(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day): Hold SBP<100 HR<60. Disp:60 Tablet(s) Refills:2 3. Lansoprazole 30 mg Susp,Delayed Release Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:900 mg Refills:2 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 6 days. Disp:18 Tablet(s) Refills:0 5. Ammonium Lactate 12 % Lotion Sig: One (1) application Topical [Hospital1 ] (2 times day). Disp:60 applications Refills:2 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times day). Disp:600 mL Refills:2 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times day). Disp:90 mL Refills:2 8. Levofloxacin D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous day 6 days. Disp:6 units Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Right thalamocapsular hemorrhage Left hemiplegia HTN BPH Discharge Condition: Fair Discharge Instructions: Please take medications experience new wekaness, trouble speaking swallowing, chest pain, palpitations, please inform physician Followup Instructions: Neurology/Stroke - Please call [Telephone/Fax (1) 3767] schedule apopointment Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Urology f/u BPH [Telephone/Fax (1) 164] appt. Patient require referral PCP [Name9 (PRE) 15973]. number Helath Care Assocaites is:	[ "5990", "4019", "2859" ]
Admission Date: [2143-8-23] Discharge Date: [2143-8-27] Date Birth: [2077-7-13] Sex: Service: CCU HISTORY PRESENT ILLNESS: 66-year-old man severe CAD, status post CABG [2135] recent PCI LMCA SVG PDL [2143-7-14]. presented [2143-8-23] elective intervention brachytherapy SVG PL native RCA. patient reported feeling well without chest pain, shortness breath, dyspnea exertion. noted ejection fraction greater 60 percent [2143-7-14]. patient underwent cardiac catheterization morning arrival PCI native RCA 4 stents brachytherapy vein graft. patient tolerated procedure well approximately 6 hours later developed chest pain noted 4 10 substernal radiating throat back without shortness breath, diaphoresis, nausea vomiting. EKG time revealed ST elevation II, III, aVF. patient brought back catheterization laboratory time. found SVG PL thrombosed. artery opened catheterization laboratory, AngioJet unsuccessful graft opened Nipride subsequent TIMI 3 flow. patient persistently occluded communication native RCA vein graft. Postprocedure, sheath pull, hematoma developed patient baseline low blood pressure systolic 90s. PAST MEDICAL HISTORY: 1. Status post MI [2129]. 2. PCI LAD [2130]. 3. PCI RCA [2132], complicated stent blocking femoral artery. 4. Status post iliac repair. 5. Coronary artery bypass graft [2135] including LIMA LAD, SVG D1, SVG RPL. 6. PCI LMCA [2143-7-14], PCI SVG PVL. 7. Status post right knee arthroscopy. 8. History hemorrhoids. 9. History benign polyps. MEDICATIONS PRESENTATION: 1. Aspirin 325 mg day. 2. Lopressor 12.5 mg b.i.d. 3. Zocor 60 mg day. 4. Plavix 75 mg day. ALLERGIES: known drug allergies. SOCIAL HISTORY: Smokes 10 packs week past 50 years, currently trying quit. Social tobacco illicits. FAMILY HISTORY: brother died MI age 60. Father first MI 50s. patient married several children. currently jobs. procedure, patient admitted CCU monitoring. PHYSICAL EXAMINATION: temperature 98.2 degrees, blood pressure 99/48, respiratory rate 15, 100 percent saturation room air, heart rate 57 66. general, well-appearing elderly male, alert oriented appropriate affect. HEENT revealed JVD. Supple neck. Chest revealed clear lungs, rhonchi, crackles. Cardiovascular normal S1, S2, murmurs, rubs, gallops, S3 S4. Abdomen flat, soft, nontender, nondistended, normoactive bowel sounds. Extremities warm capillary refill less 3 seconds, 2 plus DP PT radial pulses, edema, left groin bruit. LABORATORY DATA: EKG presentation sinus rate 55, inferior T-wave inversions, ST elevation V1 V2. IMPRESSION: patient 66-year-old male severe CAD, status post brachytherapy, SVG PDL subsequent thrombosis, status post opening artery repeat catheterization. HOSPITAL COURSE: patient hemodynamically stable resolution EKG changes ST elevation admitted CCU monitoring. evening, patient complained back pain left side, attributed lying back. exam, palpable hematoma, bruit auscultated strong DP pulses warm extremities. CT pelvis abdomen negative retroperitoneal bleed. determined patient's pain due back pain; however, concern low blood pressure, lack evidence retroperitoneal bleed. patient bolused 250 cc IV fluid blood pressure increased range 98 106/50s 60s. patient also noted hematocrit 29.5, transfused 1 unit. catheterization, patient prolonged groin bleeding requiring clamp; stated ultrasound noted small hematoma without aneurysm CT negative retroperitoneal bleed. patient low blood pressure persistently. evidence tamponade, evidence bleeding, evidence adrenal insufficiency patient responded well small boluses fluid. presumably due preload dependent. patient 3 beats NSVT telemetry otherwise feeling quite well; recurrence chest pain. Given persistent hypotension, patient remained intensive care unit 24 hours. given cosyntropin stimulation test rule adrenal insufficiency. inconclusive. given hydrocortisone 100 mg empiric treatment effect blood pressure; therefore, determined highly unlikely low blood pressure due adrenal insufficiency likely extensive vagal phenomenon pressure groin status post procedure. Given patient well, transferred floor day 3. Blood pressure remained low 90s/60s. patient continued receive boluses mild effective increase; however, patient profoundly good urine output urine lytes supported patient euvolemic. patient ambulated well, complaints. restarted back home medications including blood pressure medications. coronary artery disease, extensive, patient's CK declined, maintained aspirin, Plavix Lipitor 80. restarted Lopressor going home tolerated well without difficulty hypotension. patient consulted extensively smoking cessation. patient repeat echocardiogram revealed EF 50 55 percent, mild inferior wall hypokinesis compared previous study hoped would restart Ace inhibitor titrated time blood pressure tolerated outpatient. anemia, patient's hematocrit remained stable. determined small arterial bleed status post catheterization; received 1 unit blood. evidence AV fistula. patient instructed hematocrit followed primary care doctor. patient's hypotension determined due vagal phenomenon. patient near baseline blood pressure. evidence adrenal insufficiency patient asymptomatic. discharged plans blood pressure checked titrate medications tolerated. DISCHARGE INSTRUCTIONS: patient discharged home instructions take Plavix every day ordered stent would close. instructed never smoke again. instructed regarding new medications. FINAL DIAGNOSES: 1. Coronary artery disease. 2. Acute stent thrombosis, status post cardiac catheterization stenting. 3. Anemia due blood loss. 4. Groin hematoma. 5. Hypotension. 6. Hypokalemia. 7. Tobacco use. FOLLOW UP: patient instructed followup cardiologist, Dr. [Last Name (STitle) 837], [2143-11-27]. instructed another stress test according Dr. [Last Name (STitle) 837] [2143-11-18]. instructed call primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 838] seen within 2 weeks discharge. DISCHARGE CONDITION: Good. DISPOSITION: patient discharged home. DISCHARGE MEDICATIONS: 1. Nitroglycerine used sublingually p.r.n. 2. Aspirin 325 mg daily. 3. Plavix 75 mg daily. 4. Metoprolol 25 mg total tablet taken, half tablet p.o. b.i.d. 5. Nicotine patch 14 mg 24 hours used daily. 6. Lipitor 80 mg daily. 7. Bupropion 150 mg sustained release tablet instructed take 1 daily. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 839], [MD Number(1) 840] Dictated By:[Last Name (NamePattern1) 841] MEDQUIST36 D: [2143-10-21] 18:50:31 T: [2143-10-22] 08:03:37 Job#: [Job Number 842]	[ "4019", "2720" ]
Admission Date: [2136-10-23] Discharge Date: [2136-10-24] Date Birth: [2056-7-14] Sex: Service: NEUROSURGERY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: Found Major Surgical Invasive Procedure: None History Present Illness: 80M p/w large R IPH intraventricular extension, midline shift, hydrocephalus. patient found lying face bathtub shaved. water tub shower turned on. found neighbor. [Name (NI) ] EMS, moaning "tone left arm" may consistent posturing. taken [Hospital1 18] [Location (un) 620] head CT performed, revealing large intraparenchymal hemorrhage extending lower midbrain hypothalamus, thalamus basal ganglia right, significant mass effect, intraventricular extension casting right ventricle blood product posterior [Doctor Last Name 534] left lateral ventricle. [Hospital1 18] Neurosurgery called review imaging reported exam- Mannitol 100gm Decadron 10mg x1 recommended given. transferred [Hospital1 18] Neurosurgical evaluation. Dr [Last Name (STitle) ] discussed offered surgical intervention, refused based family's knowledge wishes prolong life incapacitated. also signed DNR/DNI order. clear want dependent disabled. family asked maintain intubation family members arrive inside outside [State 350]. offered organ donor. Past Medical History: - DIABETES TYPE II - HYPERLIPIDEMIA - GLAUCOMA - OSTEOARTHRITIS - CAROTID STENOSIS left 60-69%, rt 50 - VASOVAGAL SYNCOPE - BACK PAIN Family History: NC Physical Exam: eye opening, pupils 2mm minimally react. corneal left, minimal corneal right. Extensor posture LUE, RUE attempts localize, BLE withdraw noxious stim. gag, overbreathing vent. Tone increased left arm, normal bulk. Toes downgoing bilaterally. Pertinent Results: FINDINGS: large intraparenchymal basal ganglionic based hemorrhage. multilobulated nature greatest extent measures 6.5 x 5.3 cm. causing mass effect shift normally midline structures approximately 1.1 cm level hemorrhage. also intraventricular extension ipsilateral contralateral lateral ventricles. effacement ipsilateral frontal [Doctor Last Name 534] lateral ventricle Brief Hospital Course: Pt admitted neurosurgery service ICU. organ bank contact[Name (NI) ]. [Name2 (NI) ] extubated [10-24] without incident morphine drip started titrated respiratory rate. passed away [10-24] 12:55 p.m. family declined post morteum exam. Medications Admission: None Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2136-10-24]	[ "2724" ]
Admission Date: [2185-11-11] Discharge Date: [2185-11-17] Date Birth: [2110-10-25] Sex: F Service: CCU HISTORY PRESENT ILLNESS: Patient 75-year-old female history Alzheimer's dementia, coronary artery disease status post coronary artery bypass graft [2174] history five myocardial infarctions, last [2185-7-28] well congestive heart failure ejection fraction 30%, hypertension, dyslipidemia. [2185-11-11], experienced transient episodes left arm weakness associated slow speech. husband called patient's doctor recommended present emergency room. arrival vital signs stable. Labs unremarkable. Cardiac enzymes negative initially. admitted Neurology work question TIA stroke. underwent MRI head upon admission negative acute process. floor [2185-11-11], noted become tachycardic sinus rhythm 150 noted rales exam. given 40 mg IV Lasix without significant response; received second dose 40 mg IV Lasix code called subsequently noted drop oxygen saturation mid 80s 100% nonrebreather. also became hypotensive systolic blood pressure 70s. intubated briefly required Dopamine maintain blood pressures. transferred Coronary Care Unit management congestive heart failure. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft [2174]. 2. Diabetes mellitus. 3. Dyslipidemia. 4. Congestive heart failure, ejection fraction 30%. 5. Alzheimer's dementia. primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) 1537]. neurologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. MEDICATIONS HOME: 1. Lisinopril 50 mg p.o. q.d. 2. Imdur 60 mg p.o. q.d. 3. Prilosec 20 mg p.o. q.d. 4. Lasix 40 mg p.o. q.d. 5. Potassium chloride 10 mEq p.o. q.d. 6. Coreg 6.25 mg p.o. q. 3.125 mg p.o. q. PM. 7. Colestid breakfast supper. 8. Aspirin 325 mg p.o. q.d. 9. Folate 1 mg p.o. b.i.d. 10. Lanoxin 0.125 mg p.o. q. Monday, Wednesday Friday 0.25 Tuesday, Thursday, Sunday. ALLERGIES: 1. Sulfa. 2. Iodine. SOCIAL HISTORY: lives husband. smoke drink. PHYSICAL EXAMINATION: Upon admission Coronary Care Unit, intubated sedated. pink, frothy sputum suctioned G tube. lungs audible rales bases. regular rate rhythm audible upon precordial exam audible extra heart sounds. abdomen benign positive bowel sounds. edema 1+ distal pulses. responding stimuli, sedated. LABORATORY: Upon admission Coronary Care Unit sodium 134, potassium 4.4, chloride 97, bicarbonate 25, BUN 20, creatinine 0.7, glucose 124, INR 1.1. White count 7, hematocrit 33, platelets 211. EKG normal sinus rhythm 90 beats per minute left axis, left bundle branch block. comparison available time. Chest x-ray patchy vascular markings consistent congestive heart failure. HOSPITAL COURSE: initial impression admission Coronary Care Unit patient 75 year-old female severe coronary artery disease developed symptoms left arm discomfort day prior admission. may may represented anginal type symptoms. admitted directly floor apparently decompensated congestive heart failure setting elevated systolic blood pressure (as high 200). patient able weaned Dopamine expeditiously upon admission Coronary Care Unit. diuresed aggressively successfully IV Lasix. PA catheter placed upon admission order guide management initial pulmonary artery pressures 35/10 pulmonary capillary wedge pressure 10. note, following aggressive diuresis. patient well subsequent titration load reduction Captopril initiation Isordil. able extubated successfully [2185-11-14]. underwent transthoracic echocardiogram revealed severely depressed LV function ejection fraction 20 30% akinesis inferior row posterior walls moderate hypokinesis LV well 1+ AR MR. patient subsequently well time dictation [2185-11-17], awaiting transfer General Medical Floor await eventual disposition likely short term rehab. TRANSFER STATUS: Stable. DISCHARGE STATUS: Pending. MEDICATIONS TIME DISCHARGE CORONARY CARE UNIT: [Unit Number ]. Lasix 100 mg p.o. q.d. 2. Isordil 30 mg p.o. t.i.d. 3. Heparin 5000 units subcutaneous b.i.d. 4. Captopril 75 mg p.o. t.i.d. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Regular insulin sliding scale. 9. Levaquin 250 mg p.o. q.d. discontinued [2185-11-22]. 10. Flagyl 500 mg p.o. t.i.d., last dose given [2185-11-22]. DISCHARGE DIAGNOSES TIME TRANSFER CORONARY CARE UNIT: [Unit Number ]. Decompensated congestive heart failure. 2. Hypertension. 3. Alzheimer's dementia. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Last Name (NamePattern1) 25313] MEDQUIST36 D: [2185-11-17] 14:32 T: [2185-11-17] 14:45 JOB#: [Job Number 106144]	[ "4280" ]
Admission Date: [2195-10-9] Discharge Date: [2195-10-13] Date Birth: [2131-8-11] Sex: Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5129] Chief Complaint: mental status changes, shortness breath Major Surgical Invasive Procedure: none History Present Illness: 64 yoM history dCHF, COPD 2L home O2 (noncompliant), OSA phtn, hypertension, recurrent GI bleeds setting acquired [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease, MGUS treated chemo velcade dexamethasone x4 weeks ongoing treatment recently hospitalized dyspnea exertion weakness, discharged [10-8] [Hospital1 18]. . last hosptialization dyspnea thought multifactorial diastolic CHF, COPD pulmonary hypertension. treated diuresis nebulizers. symptoms completely resolve. presented day admission oncology clinic chemotherapy, prior initiation reported feeling winded short ambulation, ambulatory O2 sat 78%, returning 94% rest. Repeat ambulatory sats 85%. referred ED. get scheduled chemo. . ED, V/S 97.2 66 99/85 18 100% 4L. noted slightly confused, sats low 90s 4L. ABG 7.23/ 117 /90 /52. Crackles noted exam. given Levofloxacin 500mg po, prednisone 60mg Duoneb X 1. Labs significant CO2 5, BNP 2166 similar recent admission. CXR could rule L basilar infiltrate. transfer, V/S 128/59, 77, 95% 2L. mentating appropriately. Repeat ABG 7.33/86/63/47. . floor: Pt satting 95% 2L, respiratory distress feels comfortable. Past Medical History: Recurrent GI bleeds [2-25] AVMs [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] Disease, acquired MGUS s/p bone biopsy plasma cell dyscrasia without evidence multiple myeloma Hypertension dCHF pulmonary hypertension COPD 2L NC home, noncompliant OSA-untreated, non-compliant Secondary hyperparathyroidism Dyslipidemia h/o respiratory failure hypercarbia associated episode pneumonia diastolic failure Morbid obesity Ventral hernia repair [2192] Social History: Lives 20 year-old son [Location (un) 686]. Retired correctional officer since [2188]. Smoking: None currently. h/o 0.5ppd - 1ppd x 35 years. EtOH: None Illicits: Marijuana, occasional joint x15 years Family History: Father: prostate cancer 48, diabetes, died colon cancer 78 Sister: stroke, [Year (4 digits) 14165] cell trait, kidney transplant, sarcoid Extensive family history hypertension FH heart disease Physical Exam: Admission PEx: Vitals: T:98.9 BP:156/75 P:103 R:15 O2:95%2L General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult assess, LAD Lungs: Pt able speak 5 words breaths. Lungs scattered expiratory wheezes, evident rales rhonchi, though breath sounds distant. Prolonged expiratory phase. CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema, pneumoboots place . Pertinent Results: Labs Admission: [2195-10-9] 09:30AM BLOOD WBC-4.4 RBC-4.03* Hgb-11.2* Hct-33.4* MCV-83 MCH-27.7 MCHC-33.5 RDW-16.6* Plt Ct-211 [2195-10-9] 09:30AM BLOOD PT-13.0 PTT-39.4* INR(PT)-1.1 [2195-10-9] 01:51PM BLOOD Neuts-78.8* Lymphs-13.0* Monos-5.9 Eos-1.8 Baso-0.4 [2195-10-9] 09:30AM BLOOD Gran Ct-3580 [2195-10-9] 09:30AM BLOOD Ret Aut-3.2 [2195-10-8] 05:40AM BLOOD Glucose-117* UreaN-26* Creat-1.2 Na-136 K-4.5 Cl-91* HCO3-41* AnGap-9 [2195-10-9] 09:30AM BLOOD ALT-17 AST-62* LD(LDH)-193 AlkPhos-53 TotBili-0.3 [2195-10-9] 01:51PM BLOOD proBNP-2166* [2195-10-9] 09:30AM BLOOD TotProt-7.3 Calcium-9.0 Phos-3.9 Mg-2.1 Iron-33* [2195-10-9] 09:30AM BLOOD calTIBC-407 Ferritn-58 TRF-313 [2195-10-9] 09:30AM BLOOD PEP-PND b2micro-3.9* [2195-10-9] 03:12PM BLOOD pO2-90 pCO2-117* pH-7.23* calTCO2-52* Base XS-15 [2195-10-9] 08:47PM BLOOD Type-ART pO2-63* pCO2-86* pH-7.33* calTCO2-47* Base XS-14 [2195-10-10] 11:20AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2195-10-10] 11:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2195-10-10] 11:20AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-2 [2195-10-10] 11:20AM URINE CastHy-1* [2195-10-10] 11:20AM URINE Mucous-RARE [2195-10-10] 11:20AM URINE Micro: MRSA pending Labs Discharge: Brief Hospital Course: 64yo male acquired [Name Prefix (Prefixes) ]-[Last Name (Prefixes) ]'s disease associated MGUS, recurrent GI bleeds, diastolic HF, pulmonary HTN, severe COPD 2L, OSA (refuses use BiPAP), p/w acute chronic hypercarbic/hypoxemic resp failure likely [2-25] untreated severe OSA, PH, COPD exacerbation, chronic CHF. initially admitted ICU, intubated. #Acute chronic respiratory failuredue OSA COPD: -initially felt likely [2-25] CHF COPD exacerbation underlying severe untreated OSA/OHS. obvious pneumonia CXR pt remained afebrile w/o leukocytosis. mental status/somnolence hypercarbia improved BiPAP set 18/10 4L O2. Suggest use BiPAP overnight naps. -He need retitration sleep study outpt optimize close follow-up sleep/pulm doctor [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (we emailed Dr. [Last Name (STitle) ] issue). transferred medical floor well. sufficiently concerned indicated would use BiPAP home instructed. #CKD - creatinine rise 1.2 admission 1.7 diuresis ICU. Looking back previous labs, creatinine fluctuated range past (was 1.9 [2195-8-24]), cause renal failure identified. Potentially nephrotoxic meds held, #MGUS: f/u UPEP #HTN: continue home meds #Nutrition consult obesity/dietary input. 64yo male severe COPD continuous home O2, OSA (in past refused use BiPAP), acquired [Name Prefix (Prefixes) ]-[Last Name (Prefixes) ]'s disease associated MGUS, recurrent GI bleeding, diastolic HF, pulmonary HTN, presented dyspnea likely COPD exacerbation. . # Acute chronic respiratory failure requiring ICU stay intubation - MICU team felt COPD exacerbation main component started high dose steroids, Abx, nebulized bronchodilators - evidence bronchospasm exam - tapering steroids rapidly -D/C levofloxacin - wean O2 maintain sats 88-92%, home flow 2L/min via NC. Check ambulatory sats - OSA likely large component - needs wear BiPAP night. last evening sats dropped 93% (good) . # Acute kidney injury -admission creat = 1.0, gradually increasing - 1.8. -FeNa yesterday = 0.95%, suggesting pre-renal azotemia creatinine continues increase despite IV hydration holding ACE-I -no evidence urinary retention (PVR < 350) -He seen consultation Nephrology [2195-10-12], agreed trial IV hydration holding ace-inhibitor diuretic. discharge serum creatinine 1.7. # Acute chronic diastolic heart failure -last echo [2195-6-24] showed right heart failure (likely due chronic lung disease resulting pulmonary hypertension) preserved LV function -no evidence acute HF - received torsemide inthe ICU resulting decrease BNP, increase creatinine - floor, held diuresis -there peripheral edema . # OSA: -has follow pulm discharge pt states inclined use nighttime BiPAP. . # Htn: Continue carvedilol. Lisinopril D/C'd setting rising creatinine . # MGUS: Patient bortezomib velcade treat MGUS-associated VWd subsequent GIB. - updated Dr. [Last Name (STitle) 3060] patient rehospitalized. - need reschedule next treatment. - Beta-2 Microglobulin elevated 3.9 (0.8 - 2.2 mg/L) ABNORMAL BAND GAMMA REGION IDENTIFIED PREVIOUSLY MONOCLONAL IGG KAPPA REPRESENTS ROUGHLY 6% (440 MG/DL) TOTAL PROTEIN -FREE KAPPA, SERUM 43.4 H 3.3-19.4 mg/L FREE LAMBDA, SERUM 19.1 5.7-26.3 mg/L FREE KAPPA/LAMBDA RATIO 2.27 H 0.26-1.65 -He also followed Dr. [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ] . # [Name Prefix (Prefixes) ]-[Last Name (Prefixes) ]'s disease - asx, blood counts remained stable. - trended CBC # Code: Full (discussed patient) #code status: full Medications Admission: 1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO twice day. 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO day. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times day). 6. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times day: 2 puffs po four times day needed shortness breath use 15 minutes activity. 8. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed Constipation. 3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) Inhalation every 4-6 hours needed sob/wheeze. 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Acute chronic hypercarbic respiratory failure COPD Obstructive sleep apnea Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted respiratory difficulty likely due poor oxygenation COPD obstructive sleep apnea pulmonary hypertension. may also component heart failure well. vitally important use BiPAP machine whenever sleeping, discussed. Continue use oxygen nasal cannula awake, doing. Maintain low salt diet watch closely evidence heart failure (leg swelling, increasing weight, and/or increasing shortness breath). Weigh every morning, call primary care doctor cardiologist weight goes 3 lbs. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: [Last Name (Prefixes) ] [2195-10-16] 9:00 With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital1 7975] INTERNAL MEDICINE When: SATURDAY [2195-10-17] 11:30 With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, MPH [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: CAMPUS Best Parking: Free Parking Site Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2195-10-19] 9:00 With: [First Name8 (NamePattern2) 2191] [Last Name (NamePattern1) ], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "4019", "4280" ]
Admission Date: [2196-7-26] Discharge Date: [2196-7-29] Date Birth: [2120-2-8] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Augmentin Attending:[First Name3 (LF) 602] Chief Complaint: coffee ground emesis Major Surgical Invasive Procedure: EGD History Present Illness: Patient severely demented baseline history obtained via [Hospital1 1501] records. . 76 y/o F history CHF, Afib coumadin, HTN, dementia prsented living facility vomiting coffee grounds earlier today. Per records, patient suffering constipation. Bowel regimen aggressively uptitrated day prior admission, patient given magnesium citrate. Patient began vomiting coffee grounds several occasions. Unclear patient fevers chills, abdominal discomfort. . ED patient's initially VS 99.7 140 167/110 22 99%4LNC. Patient triggered HR. Exam unrevealing. Initial EKG demonostrated SVT. Patient given total 12mg adenosine revealed atrial flutter. Patient given total 40mg IV diltiazem 1LNS. NGL completed showed 1L coffee grounds clots. apparently cleared additional 500cc NS. GI consulted planed scope patient AM. Patient started protonix gtt. Lab findings significant WBC 18, Hct 44.5 (both thought hemoconcentrated) Na 129 Cr 1.2. INR noted 3.3. Patient received total 10mg vitamin K 1 unit FFP. Lastly pt spiked 101; blood cultures taken pt given ceftriaxone ?UTI. Prior transfer, vital signs 125/62 144 (still flutter) 98% RA. . MICU, patient resting comfortable complaining thirst. Past Medical History: s/p CVA HTN DM flutter Neurogenic bladder Obesity Social History: Lives [Hospital3 2558]. Per patient, son visits frequently. Family History: Non-contributory Physical Exam: ADMISSION EXAM: Vitals: 124/88 144 94% RA General: alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema . DISCHARGE EXAM: Vitals: 98.8 126/62 80 18 98% RA GEN: Alert oriented person, place, time living situation HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: Irregular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: Incontinent Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Skin: coalesced diffuse erythematous blanching patch upper back crossing midline. Scaly. Two 2 cm scaly plaques bilateral knees. Excoriations right lower leg. itchy coalesced diffusely erythematous blanching patch L buttocks Neuro: Facial droop right, 0/5 strength LUE atrophied left hand, 3/5 strength L gastroc anterior tibial, consistent baseline [1-27] distant MCA stroke. . Pertinent Results: Admission Labs: [2196-7-26] WBC-18.0# RBC-5.70# Hgb-14.9# Hct-44.5# MCV-78* MCH-26.1# MCHC-33.5 RDW-17.0 Plt Ct-451* [2196-7-26] Neuts-84.9* Lymphs-10.2* Monos-4.3 Eos-0.4 Baso-0.3 [2196-7-26] PT-33.1* PTT-29.4 INR(PT)-3.3* [2196-7-26] Glucose-283* UreaN-25* Creat-1.2* Na-129* K-3.5 Cl-83* HCO3-30 AnGap-20 [2196-7-27] ALT-8 AST-11 LD(LDH)-147 AlkPhos-76 TotBili-0.6 [2196-7-26] Calcium-10.3 Phos-2.3* Mg-2.8* . DISHCARGE LABS: [2196-7-29] WBC-8.4 RBC-4.35 Hgb-11.6* Hct-35.2* MCV-81* MCH-26.7* MCHC-33.0 RDW-17.6* Plt Ct-254 [2196-7-29] Glucose-152* UreaN-10 Creat-0.8 Na-136 K-3.4 Cl-102 HCO3-21* AnGap-16 [2196-7-29] Calcium-8.8 Phos-1.2* Mg-2.0 . Micro: [2196-7-27] 1:44 MRSA SCREEN Source: Nasal swab. FINAL REPORT [2196-7-28] MRSA SCREEN (Final [2196-7-28]): POSITIVE METHICILLIN RESISTANT STAPH AUREUS. . Imaging: EGD: Esophagus: Mucosa: Grade esophagitis stigmata recent bleeding seen starting 15 cm incisors GE junction, compatible severe erosive esophagitis likely GERD. Stomach: Excavated Lesions Multiple superficial non-bleeding ulcers ranging size 1 cm 1 cm found fundus, stomach body, antrum . Duodenum: Mucosa: Normal mucosa noted. Impression: Grade esophagitis 15cm GE junction compatible severe erosive esophagitis likely GERD Ulcers fundus, stomach body, antrum Normal mucosa duodenum Otherwise normal EGD third part duodenum Recommendations: Follow Dr.[Name (NI) 84029] clinic 4 weeks [Telephone/Fax (1) 9891] Start high dose ppi (protonix 40mg [Hospital1 ] equivalent) 6 weeks Avoid Nsaids Continue management per inpatient GI consult team . . CT ABD/PELVIS ([7-26]): CT ABDOMEN IV CONTRAST: dependent subsegmental atelectasis lung bases. heart enlarged without pericardial effusion. coronary artery thoracic aortic atherosclerotic calcification. liver, spleen, bilateral adrenal glands normal. gallbladder surgically absent. poorly evaluated 13-mm hypodensity arising posterior aspect pancreatic body may new prior study. fatty atrophy pancreas. non-opacified stomach intra-abdominal loops small bowel normal without evidence obstruction. nasogastric tube terminates gastric fundus. colonic diverticulosis without evidence acute diverticulitis. mild bilateral hydronephrosis hydroureter. Within right kidney, fat-fluid level anterior interpolar calyx (2A:35). addition, fat-fluid level noted within mid right ureter (2A:66). Multiple hypodensities bilateral kidneys mostly new compared [2189] small characterize, may represent cysts. interval atrophy kidneys. addition, cortical thinning upper pole right kidney suggests prior infection ischemia. free air fluid abdomen. mesenteric lymph nodes meeting CT criteria pathologic enlargement. left para-aortic lymph node measuring 16 mm similar prior study (2A:42). atherosclerotic calcification abdominal aorta normal caliber throughout. Vascular calcifications also noted branch vessels. CT PELVIS IV CONTRAST: tiny fat-fluid level within anterior portion bladder (2A:82). distal ureters dilated bilaterally, scattered areas mild urothelial enhancement seen bilaterally. urinary bladder distended irregular lobulated appearance wall, diverticula. Heterogeneity noted region endometrium, possibly due underlying polyp fibroid. Adnexa sigmoid colon normal. large amount stool within rectum. free fluid pelvis. pelvic inguinal lymphadenopathy meeting CT criteria pathologic enlargement noted. BONE WINDOWS: suspicious lytic sclerotic osseous lesion identified. multilevel degenerative change thoracolumbar spine. IMPRESSION: 1. evidence bowel obstruction. 2. Irregular lobulated appearance bladder wall diverticula suggests neurogenic bladder clinical correlation recommended. Mild bilateral hydroureteronephrosis may due bladder distention. Mild urothelial enhancement could seen infection correlation urinalysis urine culture recommended. 3. Chyluria, unclear etiology. Correlation urine studies history instrumentation prior urologic procedures recommended. 4. Renal scarring right kidney suggests sequela prior infection infarction. 5. 13-mm pancreatic body hypodensity MRI could obtained evaluation clinically indicated. 6. Heterogeneous endometrium, possibly due polyp submucosal fibroid. Correlation non-emergent pelvic ultrasound recommended previously performed. study report reviewed staff radiologist. . ECHO ([2196-7-27]): mild symmetric left ventricular hypertrophy. left ventricular cavity unusually small. Left ventricular systolic function hyperdynamic (EF>75%). Doppler parameters indeterminate left ventricular diastolic function. Right ventricular chamber size free wall motion normal. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets mildly thickened (?#). aortic valve stenosis. Mild moderate ([12-27]+) aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. Physiologic mitral regurgitation seen (within normal limits). tricuspid valve leaflets mildly thickened. estimated pulmonary artery systolic pressure normal. IMPRESSION: Small LV cavity size hyperdynamic LV systolic function. abnormal LVOT flow contour seen LVOT gradient present. Mild moderate aortic regurgitation. . . CXR (PA/LAT): ([7-27]): FINDINGS: compared previous radiograph, relevant change. Lung volumes moderate cardiomegaly retrocardiac atelectasis, evidence pulmonary edema pneumonia. presence minimal pleural effusion left cannot excluded. right, pleural effusion. Brief Hospital Course: 76 y/o F CHF, dementia, Afib coumadin presenting coffee ground emesis found aflutter RVR. # GI Bleed: Patient admitted MICU coffee ground emesis confirmed nasogastric lavage. Patient tachycardic (see below), however BP stable. Hct initially 44. hydration, hct fell 35 remained stable. Patient received 1 unit FFP vitamin K supratherapeutic INR however receive packed RBCs. EGD revealed multiple superficial non-bleeding ulcers fundus, stomach body, antrum well severe esophagitis. started pantoprazole 40mg [Hospital1 ]. Patient remained hemodynamically stable subsequently transferred general medicine floors. hct remained stable around 35 episodes vomiting. able tolerate PO intake. discharged continue high dose PPI follow EGD [6-1] weeks. . # Tachycardia: Patient initially presented SVT received 12mg adenosine revealed underlying afib/aflutter RVR. HRs remained fluid unresponsive, however treated IV beta blockade. Upon restarted home dual nodal blockade, HRs became appropriate. However, pt displayed evidence tachy-brady syndrome, heart rates 150s 60s, diltiazem decreased 60mg TID remained hemodynamically stable. coumadin initially held setting acute bleed. However, GI felt risk stroke greater risk rebleeding, coumadin resumed discharge, bridged lovenox. . # SIRS: Patient met SIRS criteria heart rate WBC count. received empiric treatment ceftriaxone x1 ED. However, since clear source infection identified, antibiotics discontinued. WBC decreased 8.4 time discharge pt afebrile. UA significant large leukocytes, 101 WBC, bacteria, however asymptomatic urine culture showed mixed bacterial flora, treated. . # [Last Name (un) ]: Patient presented elevated creatinine hyponatremia, improved gentle fluid resuscitation. . CHRONIC ISSUES: . CHF: Pt dehydrated presentation. received gentle hydration remained euvolemic hospital course. . DM: Metformin held hospitalization. BG managed sliding scale insulin. resumed metformin upon discharge. . Pain management: Pt managed lidocaine patch hospitalization. complaints lower back pain. may able dc percocet continue lidocaine patch decrease constipation. . TRANSITIONAL ISSUES: Pt DNR/DNI. follow EGD GI appointment scheduled 4 weeks discharge. also several findings CT may deserve follow-up outpatient described CT findings. constipation seems issue her, may benefit pain control lidocaine patch only, reported pain well controlled regimen hospitalized. restarted coumadin given benefit stroke reduction seemed outweight risk re-bleeding, per GI. bridged lovenox. unable contact son hospitalization, however final decision continue anticoagulation addressed him. Medications Admission: - Ventolin HFA 90mcg 2 puffs q6h prn - Ipratropium/Albuterol 3cc via Neb QID prn wheezing - Acetaminophen 1000mg PO Q4h prn - Magnesium Citrate 1 bottle PO - Diltiazem 90mg PO TID - Bisacodyl 5mg PO QHS - Milk Magnesia 400mg/5mL PO 30cc QHS - Lidoderm patch - Percocet 5/325mg 1 tab PO TID - Coumadin - Bupropion XL 150mg Daily - Metformin 500mg Daily - Docusate 100mg [Hospital1 ] - Metoprolol tartrate 50mg [Hospital1 ] Discharge Medications: 1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Adhesive Patch, Medicated(s) 2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once day (in morning)). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times day). 6. warfarin 4 mg Tablet Sig: One (1) Tablet PO Daily 4 PM. 7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain. 8. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous [Hospital1 ] (2 times day): stopped INR theraputic 24-48 hours. 9. metformin 500 mg Tablet Sig: One (1) Tablet PO day. 10. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO twice day needed constipation. 11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary diagnosis: Upper GI bleed Secondary diagnosis: atrial flutter Discharge Condition: Mental Status: Confused - sometimes. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: Dear Ms [Known lastname 4318], pleasure taking care [Hospital1 827]. admitted hospital bloody vomit. upper endoscopy showed severe acid reflux ulcers esophagus stomach. this, started new medication control stomach acid. take medicine twice day indefinitely. also need follow Gastrointestinal doctors [Name5 (PTitle) 9004] repeat endoscopy [3-30] weeks. heart rate also fast came hospital. gave medication slow heart rate down, restarted home dose metoprolol diltiazem. Please make following changes medications: 1. start taking pantoprazole 40 mg mouth twice day 2. back pain well controlled lidocaine patch hospital. Since worked here, may want consider stopping percocet (it make constipation worse) using lidocaine patch instead. 3. take lovenox Followup Instructions: Department: WEST PROCEDURAL CENTER When: THURSDAY [2196-8-25] 8:00 With: WPC ROOM THREE [Telephone/Fax (1) 5072] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: GI-WEST PROCEDURAL CENTER When: THURSDAY [2196-8-25] 8:00 With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6953], MD [Telephone/Fax (1) 463] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: DIV. GASTROENTEROLOGY When: WEDNESDAY [2196-8-31] 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6953], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Please call patient registration ([Telephone/Fax (1) 99686] prior appointment. Completed by:[2196-7-30]	[ "5849", "4280", "4019" ]
Admission Date: [2174-10-13] Discharge Date: [2174-11-2] Date Birth: [2121-11-5] Sex: F Service: SURGERY Allergies: Lisinopril/Hydrochlorothiazide Attending:[First Name3 (LF) 6346] Chief Complaint: bright red blood per rectum transfer outside hospital Major Surgical Invasive Procedure: Exploratory laparotomy, lysis adhesions right colectomy ileocolostomy History Present Illness: 52 F Jehovah's witness w/ pmhx HTN presents 1 day hx BRBPR rectum, occured last night 4 episodes dark red blood mixed loose stools, clots time, denies maroon stools, dark tarry stools, 1st episode. associated lightheadness, weakness later evening w/ LOC, falls, also nausea, vomitting, abdominal pain. . Presented OSH HCT noted 30 stable VS 164/85 104 16 98RA, tx'd [Hospital1 18] ED pt jehovah's witness. . ED VS 98 88 142/70 16 99RA, received 1L NS, BRB rectal vault, GI consulted recommended bowel prep colonoscopy. Here, denies weakness, cp/sob/palpitations, dysuria Past Medical History: Diverticulosis - cscope 2 yrs ago Lap CCY [9-2] Csection x3 HTN Social History: smoking, scoial drinker adminstrative assistant Family History: colon ca/ibd, NC Physical Exam: 98.8 99 118/88 16 100RA GEN: NAD, pleasant, speaking full sentences HEENT: PERRL, EOMI, OP Clear, MMM, JVD nondistended, anicteric CV: tachycardic mrg CHEST: CTA b/l mrg ABD: Soft, +BS, NT/ND, midline cscetion scar EXT: c/c/ce Neuro: AAOx3, focal deficits Pertinent Results: OSH HCT 31.9 . EKG-NSR 90bpm, NA, NI, q wave III, STT changes [2174-10-14] 06:31AM BLOOD WBC-2.9* RBC-1.52# Hgb-4.8# Hct-13.7# MCV-90 MCH-31.3 MCHC-34.7 RDW-14.0 Plt Ct-168 [2174-10-19] 10:20AM BLOOD WBC-4.9 RBC-0.94 Hgb-2.8* Hct-8.8* MCV-94 MCH-29.4 MCHC-31.3 RDW-15.3 Plt Ct-293 [2174-11-2] 12:10PM BLOOD WBC-5.7 RBC-2.58# Hgb-6.5 Hct-23.9# MCV-92 MCH-25.1 MCHC-27.2* RDW-21.7* Plt Ct-708* [10-14] Tagged RBC Scan - Moderately brisk intermittent bleeding originating ascending colon. [10-28] CT - ?cortical infarct pyelonephritis, small simple left pleural effusion adjacent atelectasis Brief Hospital Course: Patient admitted [10-13] OSH lower GI bleed since patient Jehovah's witness continued bloody bowel movements. Patient admitted medical ICU underwent tagged RBC scan suggested bleeding eminated ascending colon. Angiography performed visualize source bleeding. patient continued BRBPR general surgery service consulted. Upon consultation patient found hematocrit 13.7 emergent colectomy offered resolve active bleeding. patient refused blood products citing religious perference patient aware risks procedure consented. patient went [10-14] underwent right hemicolectomy ileocolostomy. procedure without complications patient transfered TSICU critical condition. Patient remained ventilator several days, started erythropoetin IV Iron maximize RBC production capability. started parenteral nutritional prior return bowel function. successfully extubated pod# 10 transfered floor hematocrit stabilized. patient transferred floor hematocrit slowly increased day upon discharge 23. GI Bleed - patient continued guiac positive stool ICU however felt result retained blood colon. patient transferred floor patient episodes BRBPR evidence GI bleeding. Heme - Upon discharge patients hematocrit 23.9 significantly higher post op Hct 8. patient started 20K Units EPO continue therapy 1 week well Iron supplementation 1 month. Pulm - Post operatively patient developed left lower lobe pneumonia treated one week course cipro. Upon discharge patient afrebrile normal WBC. GI - patient started parenteral nutrition unit however advanced regular diet admission floor. Patient discharged able tolerate regular diet. CV - Patient continued tachycardic throughout hospital course result anemia. also hypertensive several occassions treated IV PO Lopressor. Upon discharge patient remained tachycardic continued episodic hypertension PCP follow on. GU - ICU patient developed enterococcal urinary tract infection treated appropriately antibiotics Dispo - Patient discharged short term rehab follow Dr. [First Name (STitle) 2819] approximately 1-2 weeks Medications Admission: Diovan 160mg Daily HCTZ 25mg Daily ASA 81mg daily MVI Discharge Medications: 1. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday) 1 weeks. Disp:3 injection Refills:0 2. NuvaRing Vaginal 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times day) 1 months. Disp:60 Tablet(s) Refills:0 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HOURS DAY (). Disp:20 Adhesive Patch, Medicated(s) Refills:1 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain/fever. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times day). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed breakthrough pain only. Disp:20 Tablet(s) Refills:0 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Lower GI bleeding Hemorrhagic Shock Acute Blood loss anemia Urinary tract infection Left Lower Lobe pneumonia Post op fluid overload Discharge Condition: Good, patient afebrile stable vital signs, tolerating regular diet, ambulating without bloody bowel movements. Discharge Instructions: Please [Name8 (MD) 138] MD go ER experience Temp>101.5, severe chest pain, shortness breath, bloody stools, severe abdominal pain, severe nausea/vomiting inability tolerate food. steri strips covering incision fall own. may shower, however keep incision clean dry. Followup Instructions: Please call Dr.[Name (NI) 11471] office schedule follow appointment approximately 1-2 weeks.	[ "2851", "4019", "5990", "486" ]
Admission Date: [2115-9-20] Discharge Date: [2115-10-16] Service: OBSTETRICS/GYNECOLOGY Allergies: Ultram / Ether Attending:[First Name3 (LF) 7141] Chief Complaint: abdominal pain, transfer OSH care Major Surgical Invasive Procedure: PICC line placement CT guided abdominal Biopsy Exploratory laparotomy Resection pelvic mass lymph node dissection Small bowel resection anastomosis Cystectomy Ileo-conduit placement Omentopexy Sigmoidoscopy 11 units blood transfusion 1 unit FFP transfusion ICU admission x 2 hypotension hemolytic transfusion reaction. History Present Illness: HPI: Ms [Known lastname ] presents daughter 3 month history worsening nausea, weight loss decreased appetite. initially evaluated admitted [Hospital 1474] hospital [Date range (1) 39208] fell back slipping wet surface. arrival, also found nausea abdominal pain time pelvic mass discovered exam. underwent CT evaluation received IVF pain meds. abdominal back pain improved vicodin darvocet. Following discharge [9-13], informed PCP Dr [Last Name (STitle) 3314] likely ovarian malignancy undergo colonoscopic evaluation. started prep Golytely felt awful this, declined actually undergo colonoscopy. . Patient came [Hospital1 18] care. Continues experience abdominal pain, confirmed large pelvic mass, 16cm, small lesions liver (cannot characterize) uncinate process. Pathology consistent either GYN primary (ovarian) vs Renal. . Per Med consult, history angina (but use NTG past months). able ADLs walk around mall without CP SOB. Denied recent RVR episodes CHF hospitalizations (maintained 40mg [Hospital1 ] lasix). Previous cardiac catheterization >2 yrs ago, interventions done. Hx MI. DM. . Per family, prior admission lost weight w/ decreased energy. Also, bowel movement 10 days. Otherwise ROS neg. Past Medical History: CHF (EF 55% echo several years ago) Mitral regurgitation Afib pacemaker osteoporosis hypothyroid PSH: TAH-BSO (40 years ago unclear reasons daughters entirely sure whether ovaries removed time), pacemaker placement [2112] Social History: Remote smoking hx. etoh. Lives independent driving previously. Several children live nearby. Family History: hx colon, breast, ovarian CA Mother hodgkin's disease Father oral cancer mets. Physical Exam: time admission: 98.2 75 120/61 16 95%RA Lying bed, appears mildly uncomfortable Gen: A&O x 3. Gait inspected. Answers questions appropriately. HEENT: thrush, [Doctor First Name ] Breasts: [Doctor First Name ], masses, nipple discharge inversion LUNGS: CTAB CVS: RRR, murmurs Back: tenderness elicited level lumber spine along bony processes. bruising seen. ABD: moderately distended, tympanic percussion RUQ/LUQ, dull percussion RLQ/LLq. Firm, non-mobile mass lower quadrants tender palpation rebound guarding. +BS. RECTAL: deferred (guaiac neg per ED resident) BIMANUAL: deferred (pt uncomfortable time) LE: 1+ pitting edema mid-calf LLE. palpable cord tenderness. Ecchymosis along medial aspect right knee shin mildly tender palpation. [4-27] motor strength hip knee flexion/extension. limited ROM kness bilaterally. effusion swelling knees bilaterally. Pertinent Results: STUDIES: PATHOLOGY: Procedure date Tissue received Report Date Diagnosed [2115-10-2] [2115-10-2] [2115-10-10] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/lo?????? Previous biopsies: [-6/3848] ABDOMEN BX. DIAGNOSIS: Pelvic mass resection: I. Pelvic mass (A-E): Epithelioid malignant mesothelioma (see note). II. Lymph node, left external iliac (F-H): malignancy identified (0/2) nodes. III. Segment bladder dome (I Z): Malignant mesothelioma involving bladder wall undermining mucosa. tumor appear arise bladder mucosa in-situ carcinoma seen. IV. Peritoneal tumor (J): Malignant mesothelioma adipose tissue. V. Bladder, vagina, pelvic mass (K-R, X-Y): Malignant mesothelioma extending vagina bladder walls. tumor appear arise vaginal bladder mucosa precursor lesion seen. VI. Segment small bowel (S-T): Malignant mesothelioma involving serosa small intestine bowel. tumor arise bowel mucosa precursor lesion seen. VII. Omentum (U-W): Malignant mesothelioma. [10-11] CXR: REASON EXAM: Assess pleural effusions pulmonary edema. Patient S/P surgery. Comparison made prior studies including recent one dated [2115-10-10]. Cardiomediastinal contour unchanged. Right transvenous pacemaker leads terminate standard position right atrium right ventricle. CHF. minimal vascular engorgement stable. Blunting left lateral costophrenic angle adjacent lung opacity unchanged, due small pleural effusion adjacent atelectasis. [10-10]: LENIs FINDINGS: Grayscale color Doppler imaging common femoral, superficial femoral, popliteal veins performed bilaterally. Normal compressibility, flow, waveform, augmentation demonstrated. intraluminal thrombus identified. IMPRESSION: evidence DVT. [10-8] LENIs RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: [Doctor Last Name ]-scale Doppler son[Name (NI) 1417] right common femoral, superficial femoral, popliteal veins performed. Normal compressibility, augmentation, flow, waveforms demonstrated. evidence intraluminal thrombus. . CT [2115-10-9] IMPRESSION: 1. New small bilateral pleural effusion associated atelectasis (left greater right). 2. Small amount ascites slightly increased size since prior study. 3. Pelvic loculated fluid collection may represent organizing postoperative fluid collection/ hematoma. Alternatively, less likely, may reflect residual tumor.There 3.7 x 4.2 cm cystic collection left aspect pelvis (series 2, image 6 7). collection faint peripheral hyperdense rim may reflect organizing postoperative fluid/hematoma. Although frank pocket gas seen within fluid collection, superimposed infection cannot excluded. Alternatively, may related residual tumor. 4. evidence colitis, free air, pneumatosis bowel obstruction. CT Scan Pelvis [2115-9-19] IMPRESSION: 1. Large heterogeneous, lobulated pelvic mass seen, likely gynecological origin. Patient recalls history TAH/BSO, however, prior records available time dictation. Less likely considerations include lymphoma (although unlikely given lymphadenopathy identified elsewhere), bladder origin. 2. Marked extrinsic compression sigmoid colon, without evidence obstruction. 3. Right sided hydronephrosis proximal hydroureter. 4. Small hypoattenuating lesions seen within liver. Metastases cannot excluded. 6. Compression fracture L1, [Last Name (un) 5487] chronicity. 7. Poorly defined low attenuation lesion uncinate process pancreas, incompletely evaluated study. Primary versus secondary neoplasm suspected. Brief Hospital Course: #Pelvic Mass: [2115-9-19] patient admitted [Hospital 61] evaluated surgical gynecological services. Abdominal CT scan showed - 15.9 x 14.2 x 15.9 cm mass , incompletely encasing sigmoid colon. Small amount oral contrast seen passing sigmoid colon. Mild dilation colon proximal mass. Given involvement sigmoid colon, patient admitted General Surgery team possible surgical resection. [9-24], CT guided biopsy performed showed features suggestive unusual ovarian adenocarcinoma. staining pattern suggests clear cell carcinoma ovary, possibly metastatic endometrial carcinoma. Adrenal, renal colonic origin unlikely. Mesothelioma unlikely, cannot entirely excluded based available information. Given pathology findings, patient transferred GYN ONC service management. patient underwent exploratory laparotomy, pelvic mass resection cystectomy ileoconduit placement Drs [First Name8 (NamePattern2) ] [Name (STitle) 1022] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 365] [10-2]. Please see operative note details. patient admitted ICU postoperatively given 2 minutes hypotension surgery. #Nutrition/GI: Preoperatively, PICC line placed TPN given minimal PO intake. Postoperatively, patient's TPN restarted. TPN restarted following surgery. Nutrition consult following. patient passed flatus bowel movement postoperatively; diet advanced regular. TPN continued time discharge due limited PO intake. patient refused TPN time discharge. patient underwent sigmoidoscopy revealed normal 15cm unable advance scope due insufficient bowel cleansing. #ID: patient started Flagyl/Keflex postoperatively empiric treatment given extent surgery. -Pseudomonas infection: Postoperatively, WBC noted double 12 25. Peak WBC 39 ICU. Blood cultures, JP fluid cultures, urine culture ileo-conduit wound culture obtained. Pan-sensitive pseudomonas returned urine, wound JP drainage. ID consult recommended IV PO vancomycin Zosyn. CT scan performed demonstrated post operative fluid collection vs hemotoma vs. organizing infection. interventional radiology consult stated fluid not-amenable drainage. patient's WBC improved IV antibiotic treatment patient remained afebrile, surgical management pursued. antibiotics narrowed Zosyn IV. patient receive PICC line IV treatments total 14 days following discharge. WBC normal time discharge. repeat urine culture pending time discharge; bacteria present urinalysis. #Respiratory: patient extubated postoperative 2. patient remained room air. CT scan [9-27] performed evaluate pulmonary metastasis; workup negative. patient experienced acute dyspnea postoperative day 9 blood transfusion. received 2 doses albuterol nebulizers; desaturated 89% room air. needed minimal oxygen support upon readmission ICU. discharged room air. #Heme: patient's HCT followed closely. patient received 9 units blood surgery initial postoperative stay keep HCT 25. postoperative day 9, patient's hematocrit noted slowly dropping 28 -> 26 -> 23. unclear cause hematocrit drop: slow bleeding operative site vs hematoma. patient transfused [12-25] unit blood hemolytic reaction occurred (see below). blood transfusion discontinued immediately. 2nd ICU stay, patient received 2 additional pRBC units screened Blood Bank consultation transfusion fellow. postoperative HCT remained stable daily hemolytic reaction (bewlow) 29-30. -Hemolytic Reaction: patient experienced acute hemolytic reaction manifested acute onset dyspnea postoperative day 9. unit blood discontinued immediately. received 2 doses Albuterol nebulizer treatment. received 25 mg Benadryl, 40 mg Lasix IV 20 mg proton pump inhibitor. Due patient's acute pulmonary distress elevated respiratory rate 40, code Blue called facilitate need possible intubation. intubation cardiac resuscitation needed. transfusion fellow consult called stat. repeat type screen found JKA antibody patient's blood. patient transferred ICU monitoring. #Cardiac: patient noted atrial fibrillation prior surgery. patient rate controlled prior surgery Metoprolol Diltiazem 80s-90s. followed telemetry. medicine consult called preoperatively assessment cardiac function. Prior cardiac evaluation obtained PCP documenting ejection fracture 55% recent Echo 65% recent stress test. Following surgery, postoperative cardiac enzymes negative x 3. -Hypotension: Occurred intraoperatively patient placed 2 pressors weaned ICU. patient maintained MAP 65 per A-line. pressors discontinued time ICU discharge Metoprolol restarted. -Atrial Fibrillation: patient maintained telemetry rate controlled Metoprolol 80s-90s. restarted Coumadin tolerating adequate PO postoperative day 11. . # Pain: Patient high level post-operative pain treated morphine PCA transitioned PO due patient somnolence. Patient able wean pain medications [10-9] required minimal PO medications. . # Coagulopathy: INR elevated following surgery 1.6 attributed multiple transfusions intraoperatively. patient responded well one unit FFP INR 1.2. INR trended 1.0 spontaneously prior discharge. INR followed daily following restart Coumadin. INR 1.1 time discharge. VNA follow INR daily upon discharge. . # Hypothyroidism: levothyroxine continued . # Prophylaxis: PPI, sc heparin, aspiration precautions, pneumoboots patient accepted. . # Code: Full, confirmed w/ HCP #Dispo: Patient discharged [10-16] VNA services, ostomy care, follow Urology, INR checks followed PCP, [Name10 (NameIs) 39209] Thoracic oncology. Medications Admission: coumadin 2-5mg cardizem 240 atenolol 25 synthroid 150mcg furosemide 40 qd Discharge Medications: 1. Simvastatin 40 mg Tablet [Name10 (NameIs) ]: One (1) Tablet PO DAILY (Daily). Disp:50 Tablet(s) Refills:2 2. Latanoprost 0.005 % Drops [Name10 (NameIs) ]: One (1) Drop Ophthalmic HS (at bedtime). Disp:qs bottles Refills:2 3. Docusate Sodium 100 mg Capsule [Name10 (NameIs) ]: One (1) Capsule PO BID (2 times day) needed. Disp:60 Capsule(s) Refills:2 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:60 Tablet,Rapid Dissolve, DR(s) Refills:2 5. Acetaminophen 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) needed. Disp:60 Tablet(s) Refills:0 6. Salmeterol 50 mcg/Dose Disk Device [Last Name (STitle) ]: One (1) Disk Device Inhalation Q12H (every 12 hours). Disp:60 Disk Device(s) Refills:2 7. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 8. Warfarin 2.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY 10AM (). Disp:50 Tablet(s) Refills:2 9. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO TID (3 times day) 5 days. Disp:75 ML(s) Refills:0 10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q8H (every 8 hours) 5 days. Disp:qs piggyback Refills:0 11. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times day) needed. Disp:60 Tablet(s) Refills:0 12. Levofloxacin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 13. Xanax 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO bedtime. Disp:60 Tablet(s) Refills:0 14. Codeine Sulfate 30 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours) needed. Disp:50 Tablet(s) Refills:0 15. Levothyroxine 150 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 16. picc line care [Last Name (STitle) ]: One (1) day: PICC line care [First Name8 (NamePattern2) ] [Last Name (un) 6438] protocol . Disp:1 1 Refills:2 Discharge Disposition: Home Service Facility: Partners [Name (NI) ] [Name2 (NI) ] Discharge Diagnosis: Primary Diagnosis: -Peritoneal mesothelioma -L1 compression fracture -Acute hemolytic reaction -Pseudomonas infection Secondary Diagnoses: -Afib pacemaker -CHF -COPD -Osteoporosis -Hypothyroid Discharge Condition: Tolerating regular diet, afebrile, normal white blood cell count, ambulating. Pain controlled. Voiding ileo-conduit. Discharge Instructions: Call Dr. [First Name (STitle) 1022] if: shortness breath, fever > 100.4, abdominal pain relieved medicine, chest pain, redness around incision expanding, drainage incision, diarrhea, decreased urine output ostomy concerns ostomy. driving surgery. Please daughters/son drive you. heavy lifting 6 weeks. tub baths; may shower. scrub incision. Let water run incision. may take Codeine pain prescribed may take stool softener keep bowels regular. -Please take Levoquin 500 mg daily (1 tablet). -Please continue: -Coumadin 2.5 mg daily. Coumadin dosing checked visiting nurse dose may adjusted. Dr. [Last Name (STitle) 3314] follow dosing. -Levothyroxine 150 mcg -Latanoprost eye drops -Metoprolol 25 mg three times day -Nystatin swish/swallow three times day x 3 days -Zosyn (IV antibiotic) 5 days three times day -Salmeterol inhaler twice day -Zocor 1 tablet daily high cholesterol -Xanax 1 tablet night help sleep Followup Instructions: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7613], MD Phone:[Telephone/Fax (1) 5777] Date/Time:[2115-10-24] 10:45am [Location (un) ] [Hospital Ward Name 23] Center Thoracic Oncology [10-29] 3pm Dr. [First Name (STitle) ] [Name (STitle) ] [Location (un) ] [Hospital Ward Name 23] Building [0-0-] Dr. [Last Name (STitle) 365], Urology [11-6] 12 noon [Hospital1 9384] (across [Hospital3 1810] next [Company 38877]) [Location (un) 448] ([Telephone/Fax (1) 6441]	[ "5990", "2449", "4280", "2859" ]
Admission Date: [2170-6-1] Discharge Date: [2170-6-11] Date Birth: [2090-4-15] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Sulfa (Sulfonamide Antibiotics) / Tegretol / Statins-Hmg-Coa Reductase Inhibitors / Morphine / Plavix / Codeine / Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: exertional chest pain Major Surgical Invasive Procedure: [2170-6-1] Cardiac catheterization [2170-6-6] Coronary artery bypass graft x4 (saphenous vein graft > left anterior descending, saphenous vein graft > obtuse marginal 1 > obtuse marginal 2, saphenous vein graft > posterior descending artery) History Present Illness: 80 year old female history HTN, hyperlipidemia, prior tobacco abuse, s/p left [Last Name (LF) ], [First Name3 (LF) ], PVD, 2 month history exertional chest tightness upper chest discomfort describes "pins needles", along mild shortness breath, relieved rest. usually occurs climbing flight stairs occurred walking 50 yards following thallium. referred catheterization. Cardiac surgery consulted revascularization. Past Medical History: Hypertension Hyperlipidemia Prior tobacco abuse PVD Gout Spinal Stenosis S/p right amaurosis fugax/[First Name3 (LF) ] [2167] Arhtritis History C-Diff [2167] Scarlet fever PNA Kidney stone s/p Back surgery s/p Right [Year (4 digits) ] [2167] s/p Bilateral Cataract surgery Social History: partial native lower teeth Lives with:her son live [Name (NI) 620] Heights Occupation:retired Tobacco:smoked 1 pack per week 30 years quit [2147] ETOH:denies Family History: non contributory Physical Exam: Pulse:59 Resp:18 O2 sat:100/RA B/P Right:135/87 Left: 140/94 Height:5'5" Weight:135 lbs General:NAD, alert, cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] I-II/VI systolic Murmur best heard 2nd RICS Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+1 Left:+1 PT [Name (NI) 167]: +1 Left:+1 Radial Right: +2 Left:0 Carotid Bruit Right:+ brunit Left:+ bruit Pertinent Results: [2170-6-1] 02:40PM BLOOD WBC-6.1 RBC-3.36* Hgb-9.9* Hct-28.6* MCV-85 MCH-29.5 MCHC-34.6 RDW-15.2 Plt Ct-278 [2170-6-1] 02:40PM BLOOD Plt Ct-278 [2170-6-1] 02:40PM BLOOD PT-14.0* INR(PT)-1.2* [2170-6-6] 12:41PM BLOOD Fibrino-247 [2170-6-1] 02:40PM BLOOD Glucose-173* UreaN-8 Creat-0.6 Na-137 K-2.8* Cl-103 HCO3-26 AnGap-11 [2170-6-1] 02:40PM BLOOD ALT-12 AST-17 Amylase-64 TotBili-0.3 DirBili-0.1 IndBili-0.2 [2170-6-6] 06:17PM BLOOD cTropnT-1.00* [2170-6-7] 01:45AM BLOOD cTropnT-0.47* [2170-6-2] 06:15AM BLOOD Albumin-3.9 Mg-2.1 Cholest-211* [2170-6-1] 02:40PM BLOOD %HbA1c-5.3 eAG-105 [2170-6-2] 06:15AM BLOOD Triglyc-165* HDL-45 CHOL/HD-4.7 LDLcalc-133* Chest CT FINDINGS: Multiple bilateral solid ground-glass pulmonary nodules new increased prior examination, measuring 5 mm. Biapical peripheral pleuro-parenchymal scarring persist, associated ground-glass opacities, suggestive interstitial lung disease. focal consolidation. central airways patent subsegmental levels. Evaluation intrathoracic vasculature suboptimal without intravenous contrast, interval progression diffuse atherosclerotic calcifications. origin right brachiocephalic artery, 1.5-cm segment severe stenosis demonstrates near-complete luminal occlusion. Moderate orificial stenosis left common carotid artery also appears prominent. proximal left subclavian artery, 1.4 cm segment moderate stenosis demonstrates near-complete luminal occlusion. Extensive calcifications also noted involving aortic arch root, three coronary arteries, posterior descending artery. Thoracic aorta normal caliber, measuring 3.3 cm level main pulmonary artery, 2.7 cm arch, 2.5 cm descending portion. Central pulmonary arteries unremarkable. heart normal size, without pericardial effusion. Prominent left axillary lymph node measures 9 mm, fatty hilum. Intrathoracic lymph nodes stable, measuring 5 mm superior paratracheal region, 7 mm precarinal region, 7 mm subcarinal region. Note made mild pectus excavatum. Examination tailored subdiaphragmatic evaluation, reveals dense calcification abdominal aorta severe celiac artery stenosis. Bilateral non-obstructing renal stones present. Calcifications region porta hepatis likely vascular. bones diffusely mottled sclerotic, mild multilevel degenerative changes. IMPRESSION: 1. Progression severe atherosclerosis. 2. Interstitial lung disease, multiple new pulmonary nodules measuring 5 mm. Recommend followup CT [6-10] months, depending patient's risk factors. 3. Bilateral non-obstructing renal stones. Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.6 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Left Atrium - Peak Pulm Vein D: 0.2 m/s Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 3.8 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 55% 60% >= 55% Left Ventricle - Stroke Volume: 71 ml/beat Left Ventricle - Cardiac Output: 4.25 L/min Left Ventricle - Cardiac Index: 2.53 >= 2.0 L/min/M2 Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.5 cm <= 3.0 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 2 mm Hg Aortic Valve - LVOT VTI: 25 Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: 2.3 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.8 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 257 ms 140-250 ms Findings LEFT ATRIUM: Normal LA size. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy interatrial septum. ASD 2D color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size free wall motion. AORTA: Normal aortic diameter sinus level. Normal ascending aorta diameter. Simple atheroma ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). AS. AS. AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild moderate ([12-31]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PR. PERICARDIUM: pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. TEE related complications. Conclusions left atrium normal size. left atrium elongated. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity size normal. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). Right ventricular chamber size free wall motion normal. simple atheroma ascending aorta. complex (>4mm) atheroma aortic arch. complex (>4mm) atheroma descending thoracic aorta. three aortic valve leaflets. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic valve stenosis. aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild moderate ([12-31]+) mitral regurgitation seen. pericardial effusion. Post Bypass: Patient Apaced intermittently AV paced, phenylepherine infusion 0.5 mcg/kg/min. Preserved biventricular function, LVEF >55%, wall motion abnormalities. Mrremains mild moderate. Aortic contours intact. Remaining exam unchanged. Cardiac output 5.0 LPM HR 80. findings discussed surgeons time exam. Brief Hospital Course: Ms.[Known lastname 83206] presented cardiac catheterization revealed significant coronary artery disease. Cardiac surgery consulted underwent preoperative evaluation included CT scan chest recommends follow CT scan 6 months evaluate pulmonary nodules. [6-6] brought operating room coronary artery bypass graft surgery, see operative report details. evening weaned sedation, awoke neurologically intact extubated without complications. post operative day one weaned phenylephrine started lasix diuresis. evening started betablockers/ statin/aspirin diuresis. Chest tubes epicardial wires removed per protocol. continued progress transferred step unit monitoring. Physical therapy worked strength mobility. post-operative day #5 ready discharge [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] rehab. follow-up appointments advised. Medications Admission: LISINOPRIL - (Prescribed Provider) - 5 mg Tablet - 1 (One) Tablet(s) mouth daily METOPROLOL SUCCINATE - (Prescribed Provider) - 25 mg Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s) mouth daily NITROGLYCERIN [NITROSTAT] - (Prescribed Provider) - 0.4 mg Tablet, Sublingual - [1-1] Tablet(s) sublingually q 5 minutes needed Medications - OTC ASPIRIN - (OTC) - 325 mg Tablet - 1 (One) Tablet(s) mouth daily CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 1 (One) Tablet(s) mouth daily IBUPROFEN [ADVIL] - (OTC) - 200 mg Tablet - 1 (One) Tablet(s) mouth needed back pain IBUPROFEN-DIPHENHYDRAMINE [ADVIL PM] - (Prescribed Provider) - 200 mg-38 mg Tablet - 2 (Two) Tablet(s) mouth daily HS MULTIVITAMIN IRON-MINERAL [CENTRUM] - (Prescribed Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet - 1 (One) Tablet(s) mouth daily NIACIN - (OTC) - 500 mg Tablet - 1 (One) Tablet(s) mouth daily POTASSIUM GLUCONATE - (OTC) - Dosage uncertain Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. niacin 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 9. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) needed pain. Disp:45 Tablet(s)* Refills:0 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed pain/temp. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Hyperlipidemia Peripheral vascular disease Gout Spinal Stenosis Arhtritis Kidney stone Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [Telephone/Fax (1) 170] Females: Please wear bra reduce pulling incision, avoid rubbing lower edge Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Followup Instructions: scheduled following appointments Surgeon: Dr [Last Name (STitle) ] [7-5] 1:00pm Cardiologist: Dr [Last Name (STitle) 8579] [7-10] 10:45am Pulmonary nodules preoperative CT scan - recommended Chest CT 6 months Please call schedule appointments Primary Care Dr [Last Name (STitle) 58623] [4-3] weeks [Telephone/Fax (1) 58624] Please call cardiac surgery office questions concerns [Telephone/Fax (1) 170]. Answering service contact call person hours Completed by:[2170-6-11]	[ "2851", "4019", "2724" ]
Admission Date: [2155-7-22] Discharge Date: [2155-7-26] Service: CHIEF COMPLAINT: Chest pain shortness breath requiring BiPAP. HISTORY PRESENT ILLNESS: patient 82-year-old gentleman past medical history significant coronary artery disease unrevascularized three-vessel disease ischemic cardiomyopathy ejection fraction 20% also history VTs sinus node dysfunction status post VT ablation pacer ICD placement, peripheral vascular disease, hypertension, hypercholesterolemia, admitted acute onset substernal chest pain one hour rest. patient reported associated symptoms diaphoresis shortness breath. patient took six sublingual nitroglycerins without relief given Lasix 80 mg IV en route Emergency Department. patient refused aspirin. emergency room heart rate 96, blood pressure 194/88 oxygen saturation 86% face mask, improved 95% BiPAP. Chest x-ray consistent congestive heart failure EKG uninterpretable due pacer. given aspirin, nitroglycerin transferred coronary care unit aggressive diuresis initiated congestive heart failure. diuresis, developed abdominal pains laboratory studies showed elevated amylase lipase. patient poor historian, reported vague abdominal pain approximately two weeks ago went pacer check Dr. [Last Name (STitle) ]. patient coronary care unit given gentle hydration response acute pancreatitis, patient transferred floor pancreatic enzymes trending down, however developed leukocytosis temperature 101.1. floor taking clear liquids without abdominal pain. denied back epigastric pain, patient poor historian. PAST MEDICAL HISTORY: 1. Coronary artery disease, three-vessel disease [2150-3-8]. catheterization showed 30% stenosis LM 30% PLAD 30% D1. 2. Peripheral vascular disease, status post right iliofemoral bypass [10-9] status post percutaneous transluminal coronary angioplasty left iliac [7-9]. 3. Ischemic congestive heart failure ejection fraction 20%. 4. History VT sinus node dysfunction, status post ablation pacer placement [2149]. 5. Chronic obstructive pulmonary disease. 6. Chronic renal insufficiency baseline creatinine 2.1 3.6. 7. Hypertension. 8. Hypercholesterolemia. 9. History penile implant. ALLERGIES: patient states report known drug allergies, however review computerized medical records reports allergy ACE inhibitors. SOCIAL HISTORY: previous smoker, 120-pack-year history, quit 10 years ago, denies alcohol use, lives [Location 11206], wife. FAMILY HISTORY: father died secondary leukemia mother died liver disease; information provided. MEDICATIONS ADMISSION: 1. Amiodarone 200 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Isordil 30 mg p.o. q. day. 4. Plavix 75 mg p.o. q. day. 5. Hydralazine 25 mg p.o. q. day. 6. Aspirin day. PHYSICAL EXAMINATION: Vital signs transfer floor coronary care unit temperature 101.2, blood pressure 103/58, pulse 61, respiratory rate 28, saturating 95% two liters. general confused gentleman sitting chair apparent distress. HEENT examination showed left pterygium, pupils minimally reactive bilaterally. oropharynx clear. mucous membranes dry. neck supple without jugular venous distension. chest bilateral crackles one-half way lung fields. cardiac examination revealed 2/6 systolic murmur best heard right upper sternal border greater left upper sternal border. Abdominal examination revealed positive bowel sounds, nontender palpation, tenderness epigastrium right upper quadrant palpation. Extremities revealed edema. Neurologically, cranial nerves II-XII grossly intact. [4-12] right lower extremity strength, otherwise 5/5 strength extremities right lower extremity cooler left lower extremity. LABORATORY DATA: admission white count 17, hematocrit 41, platelet count 781. Differential showed white blood cell count 63.5 neutrophils, 26 lymphocytes, 7 monocytes, 3 eosinophils, 1 basophil. Sodium 139, potassium 4.5, chloride 103, bicarbonate 24, BUN 38, creatinine 3.0, glucose 155. calcium 9.1, magnesium 2.2 phosphorous 4.5. INR 1.1, PTT 24.0. Laboratory studies admission floor showed white count elevated 21.3, hematocrit 36.6, sodium 139, potassium 4.2, chloride 100, bicarbonate 26, BUN 48, creatinine 3.2 glucose 123. phosphorous 4.0 magnesium 2.1. ALT 18, AST 24 alkaline phosphatase 84. amylase, three values, 442 911 424; lipase 882 946 166. total bilirubin 1.0. cardiac enzymes drawn, set three, showing troponins 0.01, 0.04 0.03. patient also MCV 63, TIBC 442, elevated, ferritin 11, increased. HOSPITAL COURSE: 1. Pancreatitis: patient experienced initial symptoms abdominal pain coronary care unit aggressive diuresis. ultrasound liver gallbladder showed gallbladder stones sludge. acute cholecystitis. nondilated biliary tree. atrophic left kidney limited view pancreas. obtain better imaging, obtained abdominal pelvis CT without contrast concerning chronic renal insufficiency showed inflammation pancreas. patient tolerating clears full diet floor without abdominal pain. patient's pain control purely p.r.n. basis. standing medications provided. believe pancreatitis secondary transient passage gallstones. GI consult appropriate time onset pain 24 hours, thus sphincterotomy indicated. 2. Congestive heart failure: patient weaned oxygen day discharge O2 saturation 93% room air. patient's lung examination improved diminished crackles lungs. patient kept diuretics hospital secondary chronic renal insufficiency, importantly, secondary acute pancreatitis fluid balance. patient discharged smaller dose Lasix. originally came 80 p.o. q. day discharged 40 p.o. q. day follow primary care physician regards adjustment Lasix dosage. 3. Leukocytosis: patient experienced increase white count 17.0 21.3 bandemia transferred floor neutrophils 88. patient left shift differential blood count received patient floor, 88 neutrophils. believe leukocytosis related urinary tract infection. Urine cultures pending, however two urinalyses consistent urinary tract infection elevated white blood cells bacteria. patient response treated levofloxacin 250 mg p.o. q. 48 hours total seven days. renal dosing levofloxacin. discharged medication complete course therapy. 4. Chronic obstructive pulmonary disease: patient given metered dose inhalers p.r.n. chronic renal insufficiency. creatinine higher end baseline coronary artery disease obtained pressure control hydralazine rate control amiodarone. 5. Anemia: patient microcytic anemia consistent iron deficiency anemia. started ferrous sulfate 325 mg hospital hemoglobin electrophoresis sent analysis possible thalassemia. CONDITION DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Pancreatitis. 3. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Amiodarone 200 mg p.o. q. day. 3. Hydralazine 10 mg p.o. q. 6 hours. 4. Iron 325 mg p.o. q. day. 5. Levofloxacin 250 mg p.o. q. 48 hours total seven day. 6. Clopidogrel 75 mg p.o. q. day. 7. Protonix 40 mg p.o. q. day. 8. Isosorbide dinitrate 30 mg p.o. q. day. FOLLOW-UP PLANS: call primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 6680] follow next two weeks. DR.[First Name (STitle) ],[First Name3 (LF) ] 12-953 Dictated By:[Last Name (NamePattern1) 11207] MEDQUIST36 D: [2155-7-25] 17:53 T: [2155-7-29] 15:09 JOB#: [Job Number 11208]	[ "4280", "5990", "4019", "2720" ]
Admission Date: [2159-5-24] Discharge Date: [2159-6-11] Date Birth: [2106-10-6] Sex: Service: MEDICINE Allergies: Penicillins / Lovastatin Attending:[First Name3 (LF) 7651] Chief Complaint: STEMI, motorcycle accident Major Surgical Invasive Procedure: Cardiac catheterization IABP placement Mechanical ventilation Central venous line placement History Present Illness: 52yo male presented [Hospital 19135] Hospital s/p motorcycle vs car collision. pt traveling high rate speed, swerved fell. + LOC. motorcycle found middle [Male First Name (un) ] road. wearing helmet. [Hospital1 ], alert oriented x 2. Multiple facial lacerations noted tetanus shot given. Vitals upon presentation [Hospital1 ] BP 174/101, HR 80, RR 20, 100% RA. Pelvis, chest, C-spine [Last Name (un) 22942] unremarkable. transfered [Hospital1 18] care. Prior transfer ECG obtained showed inferior ST elevations. taken cath lab. intubated using laryngoscopy due airway swelling. Cath showed thrombotic mid-distal RCA lesion stented BMS x 2. transfered CCU. U tox came back + cocaine. Plastic surgery evaluated sutured facial lacs. Trauma surgery folllowing patient along CCU team. . Unable obtain ROS [12-19] mental status. . Cardiac review systems notable absence chest pain, dyspnea exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope presyncope. . ED here, initial vitals 179/100, HR 84, RR 19, 100% O2 sat. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: family denies -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. PAST MEDICAL HISTORY: GERD, multiple orthopedic procedures (back, shoulder, knee) Social History: Tobacco history: former smoker, quit 2 months ago Family denies EtOH ilicit drug use, say he's clean 22 years. Family History: family history early MI, arrhythmia, cardiomyopathies, sudden cardiac death per pt's daughter Physical Exam: VS: T=99.3 BP=103/65 HR=102 RR= 16 O2 sat= 100% GENERAL: sedated, intubated HEENT: Periorbital ecchymosis swetting. Lips edematous. Right forehead facial lact covered dry gauze THYROID: goitre, signs hyperthyroidism CARDIAC: RR, normal S1, S2. Soft systolic murmur. thrills, lifts. S3 S4. LUNGS: chest wall deformities, scoliosis kyphosis. CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. tenderness. + BS EXTREMITIES: edema SKIN: stasis dermatitis, ulcers, scars, xanthomas. GAIT: unable assess MUSCLE: tone appears normal Pertinent Results: Admission Labs: [2159-5-24] 11:00AM BLOOD WBC-15.9* RBC-5.24 Hgb-15.2 Hct-43.0 MCV-82 MCH-28.9 MCHC-35.3* RDW-14.1 Plt Ct-214 [2159-5-24] 11:00AM BLOOD PT-11.8 PTT-20.0* INR(PT)-0.9 [2159-5-24] 11:00AM BLOOD Fibrino-288.4 [2159-5-24] 03:00PM BLOOD Glucose-190* UreaN-16 Creat-0.8 Na-135 K-4.5 Cl-103 HCO3-24 AnGap-13 [2159-5-24] 11:00AM BLOOD CK(CPK)-667* [2159-5-24] 11:00AM BLOOD Lipase-20 [2159-5-24] 11:00AM BLOOD cTropnT-<0.01 [2159-5-24] 03:00PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 [2159-5-24] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2159-5-24] 11:17AM BLOOD Glucose-170* Lactate-1.6 Na-141 K-5.1 Cl-103 calHCO3-23 [2159-5-24] 11:17AM BLOOD freeCa-1.03* Cardiac Enzymes: [2159-5-24] 11:00AM BLOOD CK(CPK)-667* [2159-5-24] 04:48PM BLOOD CK(CPK)-1662* [2159-5-24] 10:43PM BLOOD CK(CPK)-1887* [2159-5-25] 04:10AM BLOOD CK(CPK)-2627* [2159-5-25] 10:00AM BLOOD CK(CPK)-4153* [2159-5-26] 03:59AM BLOOD CK(CPK)-4480* [2159-5-26] 02:47PM BLOOD CK(CPK)-3689* [2159-5-24] 11:00AM BLOOD cTropnT-<0.01 [2159-5-24] 04:48PM BLOOD CK-MB-137* MB Indx-8.2* [2159-5-24] 10:43PM BLOOD CK-MB-163* MB Indx-8.6* cTropnT-1.50* [2159-5-25] 04:10AM BLOOD CK-MB-259* MB Indx-9.9* [2159-5-25] 10:00AM BLOOD CK-MB-438* MB Indx-10.5* [2159-5-25] 08:27PM BLOOD CK-MB-422* cTropnT-6.60* Notable Labs: [2159-6-7]: HbA1c 6/0 [2159-6-7]: ALT 35, AST 44, AlkPhos 55, TBili 0.7, Albumin 2.9 [2159-5-29]: TSH 3.0, T4 5.1, Free T4 0.88 Discharge Labs [2159-6-11]: WBC 6.7, HCT 36.1, Plt 428 Na 141, K 4.7, Cl 107, HCO3 26, BUN 15, Cr 0.9, Glucose 110 Ca 8.4, Mag 2.1, Phos 4.3 PT 14.4, PTT 26.3, INR 1.2 Admission ECG [2159-5-24]: Sinus rhythm. Compared previous tracing [2153-3-20] ST segment elevation inferolateral leads ST segment depression anteroseptal leads suggesting acute myocardial infarction inferolateral territory. Repeat ECG [2159-5-24]: Acute inferior myocardial infarction. Probably mid-right coronary lesion ST segment depression lead aVL aVR negative. ST segment elevation lead III greater lead II. A-V dissociation present. irregularity rhythm suggesting capture beats. may interference dissociation junctional rhythm rapid. Since previous tracing [2159-5-24] junctional rhythm present interference dissociation. Admission CXR [2159-5-24]: Low inspiratory lung volumes, otherwise acute cardiopulmonary process. Cardiac Cath [2159-5-24]: 1. Selective coronary angiography right dominant system demonstrated one vessel disease. LMCA angiographically apparent disease. LAD angiographically apparent disease. Cx angiographically apparent disease. RCA proximal 50% stenosis well distal 70% stenosis thrombotic ulcerated. distal RCA stenosis located proximal PL/PDA bifurcation. 2. Successful PTCA stenting distal RCA 4.5x28mm Vision BMS postdilated 5.0mm. 3. Successful PCI proximal PL 5.0x18 Ultra stent. 4. Airway compromise trauma requiring fiberoptic intubation anesthesia staff. 5. Unsuccessful PTCA distal PL cutoff 2.5mm balloon. 6. Successful rescue PTCA PDA origin 2.0x15mm Apex balloon. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. STEMI 3. Successful PCI distal RCA. 3. Successful PCI proximal PL. 4. Unsuccessful PTCA distal PL cutoff. 5. Successful rescue PTCA PDA origin. 6. Successful fiberoptic intubation anesthesia staff airway protection. CT Head w/o Contrast [2159-5-24]: acute intracranial abnormality CT C-spine w/o Contrast [2159-5-24]: evidence acute fracture malalignment cervical spine. CT Sinus/Mandidble/Maxillofacial Non-Contrast [2159-5-24]: Multiple facial fractures seen involving bilateral nasal bones, bilateral maxillary sinuses (anterior, lateral, posterior medial walls), right palatine process maxilla palatine bone, bilateral pterygoid plates, bilateral frontal processes maxillae, right lateral orbital wall right orbital floor. globes appear intact. extraocular muscle herniation seen. bilateral lamina papyracea intact. Blood seen throughout bilateral maxillary sinuses, ethmoid air cells, sphenoid sinuses frontal sinuses. Soft tissue swelling hematoma seen frontal scalp along subcutaneous emphysema extending right periorbital region along right cheek. Subcutaneous emphysema extends masticator space bilaterally, right greater left. globes appear intact. mandibular fracture seen. IMPRESSION: Multiple bilateral facial fractures involvement right lateral orbital wall floor described above. globes appear intact evidence ocular muscle entrapment seen. CT Abdomen Pelvis Contrast [2159-5-24]: 1. acute traumatic injuries seen within torso. 2. Left adrenal nodule, meet criteria adrenal adenoma exam. evaluation dedicated CT MRI adrenal glands recommended. 3. Mild dependent atelectasis lungs. TTE [2159-5-25]: mild symmetric left ventricular hypertrophy normal cavity size. moderate regional left ventricular systolic dysfunction inferior, inferolateral inferoseptal akinesis. remaining segments contract normally (LVEF = 30%). Right ventricular chamber size normal moderate global free wall hypokinesis. number aortic valve leaflets cannot determined. aortic valve stenosis. aortic regurgitation seen. Mild (1+) mitral regurgitation seen. mild pulmonary artery systolic hypertension. pericardial effusion. IMPRESSION: Moderate regional biventricular systolic dysfunction, c/w RCA-territory infarction RV infarction. Mild mitral regurgitation. Mild pulmonary hypertension. Cardiac Cath [2159-5-25]: 1. Selective coronary angiography right dominant system revealed one vessel coronary artery disease. RCA 100% occluded proximal prior stent. LCA engaged. 2. Limited resting hemodyanmics revealed severe hypotension central pressure 86/53 mmHg high dose dopamine. 3. Successful placement 40cc IABP hemodyanamic support. FINAL DIAGNOSIS: 1. One vessel coronary artery disease occluded RCA due stent thrombosis. 2. Severe hypotension high dose dopamine. 3. Successful placement IABP hemodynamic support. CT Head w/o Contrast [2159-5-29]: 1. New small right parafalcine subdural hematoma. 2. New scalp collections, left greater right, likely evolving hematomas. Overlying fascial enhancement likely inflammatory, please correlate clinically exclude possibility superimposed infection. CT Sinus Contrast [2159-5-29]: 1. Extensive facial fractures described above, overall unchanged appearance since [2159-5-24]. 2. Interval increase opacification paranasal sinuses, part due blood. common finding intubated patients. However, acute sinusitis cannot excluded, suspected clinical grounds. CT Chest/Abdomen/Pelvis Contrast [2159-5-29]: 1. acute intra-abdominal pathology source infection identified. 2. Interval development small pericardial effusion moderate bilateral pleural effusions fissural component left. Compressive atelectasis left greater right lower lobes. 3. Fatty deposition liver. 4. Interval development trace amount free fluid within abdomen pelvic cavities, well interval increase subcutaneous edema likely reflect slightly fluid overloaded status. TTE [2159-6-2]: Left ventricular wall thicknesses normal. left ventricular cavity moderately dilated. Overall left ventricular systolic function severely depressed (LVEF= 25 %) secondary extensive inferior posterior akinesis focal dyskinesis midventricular segment inferior free wall. right ventricular cavity dilated depressed free wall contractility. small pericardial effusion. effusion appears circumferential. echocardiographic signs tamponade. Compared findings prior study (images reviewed) [2159-6-1], focal dyskinesis inferior free wall present. TTE [2159-6-4]: atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity size normal. severe regional left ventricular systolic dysfunction infer-septal, inferioa, infero-lateral hypokinesis akinesis. apex appears hypokinetic. masses thrombi seen left ventricle. ventricular septal defect. right ventricular cavity mildly dilated mild global free wall hypokinesis. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve leaflets mildly thickened. Moderate severe (3+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. pulmonary artery systolic pressure could determined. small moderate sized pericardial effusion. echocardiographic signs tamponade. Compared prior study (images reviewed) [2159-6-2], change. IMPRESSION: VSD pseudoaneurysm seen. CT Head w/o Contrast [2159-6-6]: 1. acute intracranial hemorrhage. Previously seen tiny right parafalcine subdural hematoma since resolved. 2. Multiple facial fractures before, incompletely assessed study. new fracture identified. 3. Resolution small bilateral scalp hematomas. ECG [2159-6-10]: Supraventricular tachycardia ventricular premature beat. Inferior ST segment elevation Q waves wave inversions suggesting myocardial infarction, could recent/acute. wave inversion leads I, aVL V5-V6 also suggest ischemia. Clinical correlation suggested. Low QRS voltage limb leads. Brief Hospital Course: 52yo male admitted motorcycle accident found inferior STEMI, underwent emergent cardiac cath BMS distal RCA. #) STEMI - Patient brought CCU s/p emergent cardiac cath inferior STEMI, revealed proximal 50% stenosis RCA well distal 70% stenosis thrombotic ulcerated. Patient BMS placed distal RCA. evidence right ventricular ischemia/infarction. note, patient previously known h/o CAD, urine tox screen positive cocaine presentation. patient later denied recent cocaine use. TTE obtained next day revealed moderate regional biventricular systolic dysfunction, c/w RCA-territory infarction RV infarction, mild mitral regurgitation, mild pulmonary hypertension. patient developed ventricular bradycardia hypotension, Swan placed showed elevated pressures RA, RV, LA/WP indicating biventricular failure. Repeat cath following day showed thrombosis RCA stent, decision made medically manage patient point microvascular perfusion severely impaired distal embolization clot formation. Post cath gravely ill acute systolic CHF right ventricular failure. IABP placed support, gradually weaned pulled. cardiac enzymes peaked [2159-5-26]: CK 4480, MB: 300, Trop: 6.21. patient aggressively diuresed developing significant pulmonary edema, fluid balance closely monitored given pre-load dependence setting RV infarct. several repeat TTEs admission, recent echo [2159-6-4]. Echo showed severe regional left ventricular systolic dysfunction infer-septal, inferioa, infero-lateral hypokinesis akinesis, hypokinetic apex, mildly dilated RV, mild global free wall hypokinesis, mod-severe MR, small moderate pericardial effusion without evidence tamponade. #) Supraventricular tachycardia/atrial fibrillation - night initial presentation, s/p PCI, rhythm went sinus tachycardia atrial tachycardia ventricular bradycardia; BP 60-70/40s. Arrhythmia thought secondary AV nodal infarct (RCA branch) causing degree heartblock. Per EP, patient appeared 2:1 conduction higher HRs good conduction lower HRs (~50), pacemaker indicated time. [2159-5-28] patient several episodes sustained monomorphic V tach, lasting 2 min time increasing frequency. Per EP recs, patient started amiodarone bolus drip. continued several runs non-sustained V-tach, started metoprolol tartrate additional rate control. amiodarone later stopped, patient continued metoprolol. began several episodes fib/flutter [2159-6-7], without hemodynamic compromise, rhythm would spontaneously convert back normal sinus rhythm. episode symptomatic bradycardia [2159-6-10], ECG/telemetry showing retrograde p waves junctional rhythm, rate 50/min. patient subjectively SOB hypoxic, episode brief. episodes symptomatic bradycardia, patient closely monitored. note, patient episode fib/flutter [2159-6-10] received 2.5mg metoprolol IV, resultant drop BP requiring 250cc bolus NS. CHADS score 1 receive aspirin thromboembolic prophylaxis. #) Systolic heart failure: Patient left ventricular dysfunction likely seconary STEMI ejection fraction 30%. heart failure regimen includes metoprolol, lisinopril, spironolactone. initially managed lasix autodiuresing well, lasix held [2159-6-10]. need restarted outpatient prevent volume overload. #) Hypotension - night presentation s/p cath, patient developed atrial tachycardia ventricular bradycardia BP 60-70/40s. started Dopamine pressure support, would require ongoing support several pressors keep MAP goal >65. eventually weaned pressors, however SBPs generally remained 80s-90s. degree orthostatic hypotension, anti-hypertensive diuretic regimen adjusted accordingly. note, patient's SBP persistently 80s-90s days prior discharge. Patient asymptomatic SBP 80s. #) Respiratory Status - Patient sustained multiple facial fractures MVA, required intubation significant airway swelling. CCU course, gradually weaned ventilator support, successfully extubated [2159-6-3]. #) Sinusitis/Fever - early hospital course, patient persistently febrile diaphoretic. setting multiple facial fractures, started broad spectrum antibiotic coverage. Per ID, patient regimen vancomycin, aztreonam, cipro, metronidazole (given penicillin allergy). clear source infection initially identified, although felt patient may develoepd sinusitis setting facial trauma. CT sinus revealed opacification sinuses, however ENT consult feel pus, abscess fluid collection ammenable drainage. patient's antibiotic regimen tailored back metronidazole levofloxacin, 14-day course. PICC placed [2159-6-4]. patient also placed standing Tylenol time persistent fevers. Prior discharge, patient antibiotics remained afebrile. 1/4 bottles blood culture positive coag negative staph, felt contaminant. Repeat blood cultures negative. #) Facial fractures - Multiple facial fractures noted CT, including bilateral nasal bones, bilateral maxillary sinuses (anterior, lateral, posterior medial walls), right palatine process maxilla palatine bone, bilateral pterygoid plates, bilateral frontal processes maxillae, right lateral orbital wall right orbital floor. Blood present bilateral maxillary sinuses, ethmoid air cells, sphenoid sinuses frontal sinuses. globes appeared intact evidence ocular muscle entrapment. seen trauma surgery, plastic surgery, ophthomology. Plastic surgery irrigated sutured facial lacerations CCU, ophtho consulted periorbital swelling orbital fx CT. feel evidence entrapment intraoccular involvement. #) Asymmetric Pupils - Left pupil noted 1-2mm constricted right, neurology consulted. left right pupil would constrict light. Immediate CT scan could obtained secondary patient's hemodynamic instability, CT head patient medically stable revealed small subdural hematoma. Ophthomology [Name (NI) 653], felt highly unlikely intraocular pathology contributing asymmetric pupils. #) Delirium/Agitation - Patient developed agitation delirium later hospital course, thought ICU-related delirium. seen psychiatry, started regimen olanazpine mirtazapine. also responsed well additional olanzapine prn agitation. difficulty sleeping, seemed respond well trazadone prn insomnia. Patient neuropsych testing outpatient setting. #) Hyperglycemia - patient previous diagnosis diabetes, persistently hyperglycemic CCU course, requiring glargine insulin sliding scale. HbA1c 6.0. tolerate metformin, briefly started glyburide. However lower blood sugars 60s glyburide, medication stopped. need close monitoring blood sugar levels following discharge. #) FEN - patient started tube feeds via OG tube intubated. diet advanced following extubation, tolerating cardiac healthy regular diet time discharge. Medications Admission: Glucosamine HCl 1500mg w/MSM 1500ug B-50 - high energy complex Prilosec 20mg daily Omega 3 fish oil Vitamin E 400 IU Potassium gluconate 550mg MVI daily Simvastatin 20mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: [11-18] PO BID (2 times day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed Constipation. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed Constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times day) needed thrush. 9. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times day) needed Dyspepsia. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times day) needed Dyspepsia. 16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) needed insomnia. 17. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2) Drop Ophthalmic QID (4 times day) needed dry eyes. 18. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic HS (at bedtime) needed dry eyes. 19. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 56223] Discharge Diagnosis: Acute ST-elevation myocardial infarction Acute systolic heart failure Status post motorcycle accident Facial fractures Gastroesophageal reflux disease Discharge Condition: Good. Able ambulate walker. Mental status alert oriented person, place, time Discharge Instructions: admitted heart attack motorcycle accident. required cardiac catheterization, mechanical ventilation, initiation heart medications reduce risk future heart attacks. also found heart failure. Please take medications prescribed. Please attend follow-up appointments. Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs. Eat heart-healthy low sodium diet. important heart failure. Followup Instructions: Cardiology: [Hospital1 18] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD E/SH-446C [2159-6-29] 10:40 ([Telephone/Fax (1) 2037] Neuropsychology: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], PHD Date/Time:[2159-6-12] 9:00 [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX), [Location (un) ] Phone:[Telephone/Fax (1) 1690] Ophthalmology: Plesae call [Telephone/Fax (1) 24169] schedule appointment [Hospital1 18] follow-up local opthalmologist	[ "2724", "4280", "2720", "2859" ]
Admission Date: [2180-11-12] Discharge Date: [2180-11-15] Date Birth: [2126-3-6] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 759] Chief Complaint: Transferred [Hospital3 ] GI bleed, obstructive jaundice Major Surgical Invasive Procedure: ERCP History Present Illness: 54yo w/hx metastatic [Hospital3 499] ca s/p colectomy, chemo/XRT, cholangitis s/p multiple stents, basal cell CA presented [Hospital3 ] [2180-11-10] sudden onset maroon colored stool w/clots ostomy bag. States ostomy bag filled blood clots abdominal pain cramping associated output. lightheadedness, pt feels related anxiety output vs. blood loss. Pt taking ibuprofen prn x2 weeks low grade fevers. shortness breath, chest pain, nausea, vomiting. noticed increasing jaundice. started lasix several weeks ago leg swelling. Abdomen distended improving since starting Lasix. OSH, pt several episodes 500-1000ml bloody stools w/clots stoma, SBP 90-120, HR 90's, Hct 23, INR 1.5. Given 7U PRBC 1U FFP, vitamin K 10mg one dose. gastroscopy [11-11] showed evidence bleeding. Colonoscopy also done [11-12] showed bleeding near site stoma, ? changes consistent ischemic colitis right transverse [Month/Year (2) 499]. bilirubin slowly increasing max 22. fevers documented butstarted levofloxacin empirically. Today, 150-200cc blood via ostomy bag. Transferred [Hospital1 18] management. Upon transfer [Name (NI) 153], pt denies current complaints. Tolerating clears without nausea, vomting abdominal pain. Past Medical History: 1. Metastatic [Name (NI) ] Cancer: Diagnosed [6-1], treated colectomy, adjuvant chemo, XRT [Date range (1) 103587]; second course chemo ended [3-1]. Known meastatic disease. 2. Cholangitis: s/p ERCP, multiple biliary stents, last placed [10-2] ([Doctor Last Name ]) 3. Basal Cell Skin Cancer: Benign. Present since pt 20's. 100 resections. Social History: Married, retired lawyer. Quit [Name2 (NI) ] 15 years ago, 30 years 1 PPD prior. Prior heavy alchol use, roughly 10 beers/day. Family History: Father [Name2 (NI) 499] cancer, died 64. CAD/CVA. Physical Exam: 98, HR 88 (NSR), BP 103/57, RR 24, O2 99% RA Gen: jaundiced male NAD, alert, awake oriented x 3 [Name2 (NI) 4459]: MM slightly dry Lungs: R basilar crackles Heart: S1, S2, RRR, murmurs, rubs, gallops heard Abdomen: distended, slightly firm, NT, NABS; ostomy bag place minimal pink-tinged liquid Extrem: 1+ bilat edema Skin: multiple basal cell carcinomas, upper back R LE lesions non-bleeding, covered dressings Pertinent Results: Labs OSH [2180-11-10]: WBC 15.7, Hgb 8.2, Hct 23.6 (b/l 27-34), Plt 352 Pt 14.4/PTT 30.9/INR 1.5 Na 132, K 3.6, Cl 97, CO2 23, BUN 15, Cr 1.3 (0.8), Gluc 121, Ca 8 Alb 1.8, TP 6.2, Tbili 17.0 (was 5 [10-2]), dbili 10.1, APhos 769, ALT 100, AST 158 - Labs OSH [2180-11-12]: WBC 14.1, Hct 32.1, INR 1.26 Na 135, K 3.8, Cl 101, CO2 24, BUN 16, Cr 1.3, Gluc 95 TBili 22, Dbili 14.4, Alk Phos 607, ALT 102, AST 190 - [Hospital1 18] labs: [2180-11-12] 04:34PM GLUCOSE-88 UREA N-21* CREAT-1.1 SODIUM-136 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-12 [2180-11-12] 04:34PM ALT(SGPT)-114* AST(SGOT)-216* LD(LDH)-184 ALK PHOS-736* [2180-11-12] 04:34PM ALBUMIN-2.7* CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-1.7 [2180-11-12] 04:34PM WBC-13.0* RBC-3.59* HGB-11.6* HCT-32.0* MCV-89 MCH-32.3* MCHC-36.2* RDW-16.2* [2180-11-12] 04:34PM NEUTS-88.3* LYMPHS-5.2* MONOS-4.5 EOS-1.5 BASOS-0.4 [2180-11-12] 04:34PM ANISOCYT-1+ POIKILOCY-1+ [2180-11-12] 04:34PM PLT COUNT-280 [2180-11-12] 04:34PM PT-13.4 PTT-25.2 INR(PT)-1.1 Brief Hospital Course: 54yo w/metastatic colorectal cancer complicated multiple episodes ascending cholangitis secondary tumor obstruction s/p several stents presents GI bleed obstructive jaundice. 1. GI Bleed: Patient's HCT remained relatively stable throughout hospital course, seen GI team decided pursue invasive tests given recently coloscopy gastroscopy negative. also seen stoma nurse noted variceal veins edge stoma could cause bleed. Recommended pressure applications oozing. HCT remained stable, tolerating po well decided hold intervention 2. Obstructive Jaundice: history multiple cholangitis secondary obstruction metastatic cancer. Patient presented jaundiced fevers, leukocytosis. Decided go ahead ERCP tolerated procedure well. procedure, performed balloon sweep found hemobilia pus ducts. re-canulated. LFTs continued slowly trend procedure. Given hemobilia, thought bleed could secondary that. complete 7 day course Levofloxacin. 3. Metastatic colorectal cancer: Known end stage disease currently DNR/DNI. introduced idea palliative team consult patient interested wife was. Palliative team notified discussed wife per request. also abdominal distension decided hold Lasix given rise Creatinine. 4. Acute Renal Failure: Patient's creatinine stable hospital course day discharge, bumped 2.0. Unclear etiology call lab ? anicteric sample. repeat creatinine checked found 1.5. time, PCP notified made aware, informed PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] going [Last Name (STitle) 269] come draw blood Friday fax results Creatinine. Case managers also notified regarding [Last Name (STitle) 269] setup. Lasix held discharge, dosed antibiotics based renal clearance. 5. Code: DNR / DNI Medications Admission: Levoflox 500 daily Ambien 5 qhs lasix prior admission OSH Discharge Medications: 1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) needed. 2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 269] Discharge Diagnosis: Primary: 1. Cholangitis 2. GI Bleed Secondary 1. Metastatic Colorectal Cancer Discharge Condition: Fair Discharge Instructions: Please follow Primary Care Physician [Last Name (NamePattern4) ] [7-8] days. Please complete antibiotic course. Please blood drawn [Date Range 269] services Friday [11-17] results sent Dr. [Last Name (STitle) ] Fax # [Telephone/Fax (1) 103589] Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982], [Name Initial (NameIs) ].D. Where: LM [Hospital Unit Name 22399] Phone:[Telephone/Fax (1) 1983] Date/Time:[2181-1-18] 3:15	[ "2851", "5849" ]
Admission Date: [2154-2-13] Discharge Date: [2154-2-21] Date Birth: [2080-1-25] Sex: F Service: MEDICINE Allergies: Hayfever Attending:[First Name3 (LF) 2290] Chief Complaint: CC: SOB/cough Reason MICU admission: hypoxia Major Surgical Invasive Procedure: None History Present Illness: Ms [Known lastname ] 74 year-old female hx COPD home oxygen, asthma, dCHF, diabetes, remote history colon cancer presented ED several days worsening cough dsypnea. patient states last felt completely well two weeks ago. Two days ago began increasing cough, productive mucous. Denies blood mucous. fevers, admit chills night. admit left-sided rib pain coughing, chest pain. terms COPD history, never required intubation received steroids recently. [3-15] L oxygen baseline. flu shot year. one last year pneumovax last year. EMS called found satting 94% NRB coarse wheezing throughout lung fields. given 2 albuterol nebs way ED. ED, inital VS: 100.5 HR 116 BP 133/86 RR 28 Sat 92% NRB. CXR unremakrable. EKG showed sinus tachycardia. exam increased work breathing. placed continuous neb x 1 hour, tried spaced combivent nebs/nasal cannula oxygen sats dropped low 80's (82% 5L NC) placed back NRB. also given levofloxacin 750 mg IV, 2 gm IV magnesium, 125 mg IV methyprednisolone. also got 1 L NS. Per report lung exam/tachypnea improve nebs given ED. Currently states breathing much improved arrived ED. still feels slightly short breath rest now. review systems denies abdominal pain, vomiting, diarrhea, new myalgias arthralgias. admit HA slight nausea previously. Past Medical History: - COPD,emphysema-oxygen dependent, O2 2L-4L,former smoker (40yrs)Spirometry mild moderate obstructive defect, FEV1 1.17 (68% predicted) low DLCO 38% predicted. - Asthma - OSA home CPAP - Hypertension - Diastolic CHF pulmonary hypertension. Last TTE [12/2151] EF >55%, mild RV dilation preserved function, estimated TR gradient 43-63. - Arrhythmia s/p ablation - DM II - History rectal cancer s/p chemo, XRT, s/p transanal excision - Hyperlipidemia - Depression - Anxiety - OA knee s/p Lt TKR Rt TKR - h/o Shingles [2151-1-30] - s/p hysterectomy Social History: lives daughter. [Name (NI) ] daughter cooks takes care her. walks cane. retired, worked laundry. Quit smoking 12 years ago. alcohol drug use. Family History: Denies family history lung disease. Physical Exam: Admission: GEN: Elderly female laying bed slightly increased work breath. HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, supraclavicular cervical lymphadenopathy RESP: Slight accessory muscle use increased RR. Diffuse expiratory wheezing present throughout. CV: Regular slightly tachycardic. MRG. ABD: +BS, soft, NTND [Name (NI) ]: edema, 2+ DP radial pulses, clubbing present SKIN: rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength upper lower extremities. Sensation light touch intact throughout. DISCHARGE: VS: 97.7 132/65 80 24 92% 4L NC GEN: Elderly female reclining, slightly increased work breath acute distress. HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions, supraclavicular cervical lymphadenopathy RESP: Slight accessory muscle use increased RR. Diffuse expiratory wheezing present throughout. CV: RRR. S1, loud S2. murmurs, rubs, gallops. ABD: Protuberant, slightly distended. Midline scar umbilicus. +BS, soft. Tenderness deep palpation LLQ. massess. rebound gaurding. [Name (NI) ]: WWP, edema. Clubbing present. Radials, DPs 2+. SKIN: rashes abnormal lesions noted limited skin exam. NEURO: AAOx3. PSYCH: Appropriate normal affect. Pertinent Results: Admission labs: Na 132 K 4.2 Cl 95 Bicarb 27 BUN 18 Cr 0.8 Glu 242 trop <0.01 BNP 171 WBC 11.2 Hct 37.3 Plt 237 N 79% L 15% 5.2% E 0.5% PT 14.3 PTT 24.5 INR 1.2 Lactate 2.5 Micro: BCx x 3 - pending EKG: sinus tachycardia. Imaging: CXR: Mild hyperinflation. acute cardiopulmonary process. change previous CXR. TTE: left atrium normal size. atrial septal defect seen 2D color Doppler. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%). ventricular septal defect. right ventricular cavity mildly dilated borderline normal free wall function. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. Trivial mitral regurgitation seen. tricuspid valve leaflets mildly thickened. moderate pulmonary artery systolic hypertension. pericardial effusion. Compared report prior study (images unavailable review) [2153-4-9], major change. Brief Hospital Course: FOLLOW UP: - prednisone taper - titration insulin prednisone weaned Ms [Known lastname ] 74 yo female COPD home oxygen, asthma, dCHF, DM II admitted cough, dsypnea, persistent hypoxia consistent COPD exacerbation. difficult wean BIPAP stayed MICU 7 days respiratory function slowly recovered. PNA felt less likely contributing, treated 5 day course levofloxacin. Additionally, diastolic failure diursed effort improve respiratory status. # COPD Flare: Patient oxygen dependent (2-4L) baseline, persistently hypoxic low 80's ED increased oxygen support even several neb treatments admitted MICU BIPAP. require intubation. Atypical early PNA felt possible treated 5d levofloxacin. COPD treated high dose steroids, tapered 50mg discharge, tiotroprium, albuterol nebs, monteleukast, spiriva fluticasone inh [Hospital1 ]. MICU 7 days difficulty weaning BIPAP called floor HD 7. Legionella negative. need prednisone tapered rehab improves. Would slow taper given significant COPD. # Nausea/vomiting: day patient called MICU, developed nausea/vomiting overnight [2-19] elevated white count 20's labs. resolved bowel movements WBC count felt [3-13] steroids trended 16 day discharge. C. diff sent treated antibiotics. # Hyponatremia: Na 132 ED. Likely slightly dry admission. Resolved IVFs. Likely secondary hypovolemic hyponatremia. # Diabetes Type II: Patient metformin glipizide outpatient. held acutely ill. Sugars high sliding scale lantus qam added sliding scale uptitrated, attached summary. weans steroids, likely need insulin titrated. # Chronic dCHF/hypertension: Patient EF >55% last TTE [12-17]. Normal BNP ED evidence volume overload exam CXR. Mostly normotensive. continued diltiazem lisinopril added back blood pressure stable. TTE reordered due concern respiratory issues may paritally cardiac showed change (EF > 55%). Hctz added back [2-19]. BB systolic failure. # Hx arrhythmia s/p ablation: continued Diltiazem 180 mg po daily uptitrated 260 mg daily. # Depression/anxiety: continued Fluoxetine 40 mg po daily. # GERD: continued Omeprazole 20 mg po daily. # Hyperlipidemia: continued Simvastatin 40 mg po qhs # HCP: [Name (NI) ] daughter, [Name (NI) ] [Name (NI) 22771] cell [Telephone/Fax (1) 93966], home [Telephone/Fax (1) 93964] # Code: Full code, confirmed patient. Medications Admission: (per OMR) Albuterol nebs prn Albuterol inhaler 90 mcg q6h prn Diltiazem 180 mg po daily Fluoxetine 40 mg po daily Advair 500 mcg-50mcg 1 puff [Hospital1 ] Glipizide 5 mg po daily Hydrochlorothiazide 12.5 mg po daily Xopenex inhaler 45 mcg 2 pufss qid prn Lisinopril 20 mg po daily Lorazepam 0.5 mg po qhs prn Metformin 500 mg po bid Montelukast 10 mg po daily Omeprazole 20 mg po daily Simvastatin 40 mg po qhs Spiriva 18 mcg inh daily Calcium 500+D Colace Loratadine 10 mg po daily prn Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day): hold loose stool. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times day): hold loose stool. . 3. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO day. 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO day. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: [2-10] nebs Inhalation Q4H (every 4 hours) needed shortness breath wheezing. 7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. fluticasone-salmeterol 500-50 mcg/dose Disk Device Sig: Two (2) puffs Inhalation [Hospital1 ] (2 times day). 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) needed anxiety. 10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) needed cough. 15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times day). 16. prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) needed constipation. 20. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H (every 2 hours) needed constipation. 21. insulin glargine 100 unit/mL Cartridge Sig: Twelve (12) units Subcutaneous qam. 22. insulin lispro 100 unit/mL Cartridge Sig: per attached sliding scale Subcutaneous qachs. Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital ] Center [Location (un) 86] Discharge Diagnosis: COPD flare Constipation Diastolic Heart Failure Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Sating well 4L NC, patient's baseline. Discharge Instructions: admitted intensive car unit COPD worsening. treated steroids BIPAP well. also gave medication get rid fluid lungs may contributing. also abdominal pain likely constipation resolved bowel movement. continue prednisone COPD tapered get better. pleasure meeting participating care. Followup Instructions: Department: MEDICAL SPECIALATIES When: FRIDAY [2154-3-1] 10:20 With: DR [Last Name (STitle) 93967]/DR [First Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2154-3-18] 11:00 With: ECHOCARDIOGRAM [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "4280", "2724" ]
Admission Date: [2193-5-3] Discharge Date: [2193-5-15] Date Birth: [2145-4-30] Sex: Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 898] Chief Complaint: Seizure fever Major Surgical Invasive Procedure: Intubation Right internal jugular central venous line Arterial Line History Present Illness: 48 year old male mental retardation, history seizure disorder (unknown etiology, absence type, last [12-6]) came medical attention generalized seizure group home. seizure taken OSH, VS 103.4, HR 119, BP 68/32 resolving 102/67 without intervention, RR 24, O2 Sat 94% 1.5 L nasal cannula. lethargic diffuse "maculopapular blanching" rash. also noted acute kidney injury Cr 2.1 WBC count 8.3 (with 20% bands). INR 3.6 (pt chronic warfarin history DVT 2) UA, CXR, CT head without acute process. received ceftriaxone 2gm, gentamicin 120mg, fosphenytoin 1000 mg. appeared consistent drug rash recently started treatment cellulitis TMP/Sulf also presumptively treated anyphylactic shock IM epineprhine, IVF, methylprednisolone, diphenhydramine, famotidine. started dopamine gtt transferred [Hospital1 18] management. Upon arrival [Hospital1 18], VS: 98.9, P 112, BP 126/44, RR 21, O2 92% 100% non-rebreather mask. quickly weaned dopamine. point exam notable delirium/agitation, diffuse erythematous macular rash, edema, oral mucosal irritation tongue hard palate conjunctival injection. received 2-3L LR hypotension CVP ~14-17 range. persistently agitated received 2mg lorazepam 2 mg haloperidol resulting sedation progressive hypoxia requiring intubation. REVIEW SYSTEMS: Unobtainable patient initially unresponsive without enough mental status report. mother denied changes bowel bladder habits, known fevers chills prior day presentation, complaints chest pain, labored breathing, complaints. Past Medical History: -Seizure Disorder (last seizure [12-6]) -Deep Vein Thromboses 2 without history pulmonary embolism -Lower extremity cellulitis (started TMP-Sulfa [Date range (1) 83313]) -Mental Retardation -Obsessive Compulsive Disorder -Hypothyroidism -Urosepsis hospitalization [Hospital3 ] [2191]. Social History: lives group home. known smoking, alcohol, drugs. Family History: Non-contributory Physical Exam: Vitals: 98.9, P 112, BP 126/44, RR 21, O2 Sat 92%NRB -> 88%RA. General: agitated, delerious, non-communicative. HEENT: oropharynx dark, ?ulceration hard palate, trauma toungue. Neck: supple, LAD Lungs: roncherous bilaterally (airway sounds) anteriorly. CV: Regular rate, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses. Skin: diffuse, confluent, erythematous macules arms, legs, abdomen, lower extremities, sparing palms, soles. +blanching. Pertinent Results: LABORATORY RESULTS =================== Presentation: WBC-9.8 RBC-4.05* Hgb-11.8* Hct-36.3* MCV-90 RDW-14.3 Plt Ct-146* ---Neuts-93.0* Lymphs-4.1 Monos-2.6 Eos-0.3 Baso-0.1 PT-47.3* PTT-38.8* INR(PT)-5.3* Na 143, K 4.5, Cl 110, HCO3 22, BUN 16, Cr 1.5, Glu 196* ALT-34 AST-38 LD(LDH)-245 CK(CPK)-1116* AlkPhos-102 TotBili-0.5 Albumin-3.2* Calcium-6.9* Phos-3.7 Mg-1.2* UricAcd-9.0* Serum Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.007 Eos-NEGATIVE --Tox bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Discharge: WBC 5.2, Hb 11.1, Hct 32.5, Plt 459* PT 45.1, PTT 42, INR 4.8 na 144, K 3.7, Cl 108, HCO3 30, BUN 7, Cr 0.5, Glu 95 Ca 9.2, Mg 2.3, P 3.5 Studies: CEREBROSPINAL FLUID (CSF) WBC-13 RBC-373* Polys-7 Lymphs-57 Monos-0 Macroph-36 TotProt-97* Glucose-74 (HSV PCR Negative HSV 1 2) MICROBIOLOGY ============= cultures growth date RESULTS ============== ECG [2193-5-3]: Sinus tachycardia. RSR' pattern lead V1. Reverse anterior R wave progression. Clinical correlation suggested. Non-specific wave changes. Chest Radiograph [2193-5-3]: FINDINGS: Lung volumes low elevation right hemidiaphragm. bilateral infiltrates throughout lungs central greater peripheral, difficult assess cardiac mediastinal silhouettes secondary low lung volumes overlying infiltrates. left subclavian line tip SVC. EEG [2193-5-7]: IMPRESSION: abnormal portable EEG due slow disorganized background. abnormality suggestive widespread encephalopathy medication, metabolic disturbance, infection etiology. note sinus tachycardia. lateralized epileptiform features seen. Chest Radiograph [2193-5-10]: IMPRESSION: AP chest compared [5-8]: Consolidation perihilar right lung infrahilar left lung improved consistent resolving pneumonia. good evidence edema. Heart size top normal, mediastinal vasculature hard assess, pulmonary vessels minimally engorged. pneumothorax pleural effusion. Trasnthoracic Echocardiogram [2193-5-14]: Conclusions left atrium normal size. interatrial septum well visualized (suboptimal views). Left ventricular wall thicknesses normal. left ventricular cavity size normal. Overall left ventricular systolic function normal (LVEF>55%). Tissue Doppler imaging suggests normal left ventricular filling pressure (PCWP<12mmHg). right ventricular cavity borderline dilated normal free wall contractility. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve leaflets mildly thickened. estimated pulmonary artery systolic pressure normal. pericardial effusion. Brief Hospital Course: 48 year old male past medical history mental retardation, seizure disorder DVT* 2 presented seizure mental status changes found seizure. 1)Meningitis: patient presented seizure, fever 103.4, altered mental status. unable answer questions localizing symptoms. Meningitis initially suspected due skin rash, though maculopapular petechial nature. first day hospitalization received vancomycin/ceftriaxone/and acyclovir, would appropriate empiric treatment non-specified meningitis/encephalitis. Unfortunately, due difficulties obtaining LP, performed hospital day three showed pleiocytosis increased protein ultimately culture negative. Ultimately, thought consistent partially treated bacterial meningitis. Therefore, patient treated vancomycin/ceftriaxone resolution fevers improvement mental status baseline without seizures. Acyclovir stopped HSV PCR returned negative. patient ultimately need complete fourteen days antibiotic therapy meningitis. 2) Seizure: patient previous history seizures phenytoin. previous seizures grand mal, appears type occurred day presentation. likely precipitant seizure patient's infection fever, though phenytoin level also bit low. Initially, maintained IV phenytoin fospheynytoin transitioned back outpatient PO regimen mental status resolved. never showed signs seizure activity EEG obtained rule seizure activity consistent persistent epileptiform activity. 3) ? Allergic Reaction/Respiratory Failure: patient presentation rash, hypotension, per report swelling throat tongue. could consistent acute allergic reaction TMP/Sulfa given cellulitis certainly potential causative [Doctor Last Name 360]. Still, seems unlikely would react suddenly remarkably TMP/Sulfa receiving full day. Nevertheless, treated appropriately anaphylactic reaction epinephrine, histamine blocker, steroids recovered. 4) Respiratory failure: stated difficult tell patient actually anaphylactic shock leading airway compromise respiratory failure. possible etiologies would include pulmonary edema given need vigorous fluid resuscitation soon presentation oversedation emergency departments. Ultimately, patient weaned supplementary oxygen without event. 5) Altered mental status: Per patient's mother baseline mental status small child minimal verbal communication skills follows commands interacts appropriately. patient initially extremely somonolent minimally responsive raising concern non-convulsive status epilepticus. EEG consistent encephalopathy, however, patient's mental status eventually resolved baseline treatment underlying condition maximization variables. Likely due toxic-metabolic delirium context severe infection. 6) History DVT: patient history two DVT's thus presumably lifelong anticoagulation. INR initially supratherapeutic anticoagulation held transitioned low molecular weight heparin systemic anticoagulation NPO. eating, warfarin restarted LMWH stopped 24 hours therapeutic INR coumadin. 7) Non sustained ventricular tachycardia: morning [2193-5-13] patient two brief runs NSVT broke without management. discussed EP thought barring signs structural heart disease likely prognostic significance likely simply response acute illness. patient echocardiogram within normal limits episodes VT. note also happened phenytoin loaded, may contributed arrythmia. 8) FEN: patient initially required tube feeds due altered mental status lack inclination eat. self discontinued dobhoff unfortunately due desire spare another invasive process possible observed thankfully cleared enough tolerate PO around forty eight hours. tolerated full diet incident. tolerated full diet prior discharge. vital signs stable afebrile>72 hours. patient full code. Medications Admission: - atenolol 25mg po qdaily - neurontin 600mg po tid - risperdal 0.5mg po qdaily + qhs - ativan prn - dilantin 200mg po bid - levothyroxine 250 mcg po qdaily - warfarin 4.5 mg po qdaily - buspirone 30 mg po qdaily - ranitidine 150mg po qdaily - sertraline 250-mg po qdaily - clonidine 0.1mg po bid - tylenol - keopectate - peridex oral rinse - robitussin - mvi Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times day. 3. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice day: daily QHS. 4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours needed anxiety. 5. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO twice day. 6. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO day. 7. Buspirone 30 mg Tablet Sig: One (1) Tablet PO day. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sertraline 100 mg Tablet Sig: 2.5 Tablets PO day. 10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 11. Ceftriaxone Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q12H (every 12 hours) 2 days: Continue two days discharge. [2193-5-17]. 12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every eight (8) hours 2 days: Continue two days discharge. [2193-5-17]. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed temp>101 pain. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice day: hold loose stools. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times day) needed constipation. 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Daily 4 PM: Please start [2193-5-16]. Please note patient's previous home dose 4.5 mg daily. dose decreased INR [1-1] prophylaxis DVT. 18. Outpatient Lab Work coumadin PRN goal INR [1-1] Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital 4094] Hospital Discharge Diagnosis: Primary Diagnoses -Meningitis -Seizure disorder -History DVT -Acute Kidney Injury Secondary Diagnoses: -Hypothyroidism Discharge Condition: Good, mentating baseline, afebrile Discharge Instructions: admitted infection precipitated seizure. treated infection antibiotics improved. medications changed. continue antibiotics 2 days discharge (for total 14 days therapy). Otherwise medications changed. Please see doctor come local emergency department fevers, chills, night sweats, chest pain, shortness breath, inability tolerate food drink, concerning changes health. Followup Instructions: discharged facility complete recovery. discharged schedule follow appointments PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] well neurologist providers.	[ "2449" ]
Admission Date: [2126-3-22] Discharge Date: [2126-4-6] Date Birth: [2065-5-2] Sex: Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8404] Chief Complaint: COPD; s/p fall Major Surgical Invasive Procedure: EGD endotracheal intubation mechanical ventilation central intravenous line placement arterial line placement History Present Illness: Mr [Known lastname ] 60 w/ end-stage COPD home O2, CHF 3 prior suicide attempts presents [Hospital1 18] ED s/p witnessed mechanical fall one entire flight stairs tripping O2 tubing. Per wife 14 year old son, found empty bottles anti-hypertensives anti-epileptic medications including proprolol, gabapentin mirtazipine prescribed friend. [Name (NI) ] slurring words walking hunched day yesterday night 3 hours without telling wife going. Upon return, fell stairs tripping O2 tubing. Per wife subsequently called 911, lose consciousness able ask tissue prior arrival EMS. presented ED A&Ox1-2 MAE following commands. initial trauma exam, spinal tenderness good rectal tone without gross blood. ED course, pt rapidly deteriorated respiratory standpoint required intubation maintain SaO2 > 80s. Pt difficult intubation aspirated thick olivey liquid field, treated CTX/Flagyl. (He heavy dinner consisting mashed potatoes, meatloaf, scone ice cream). . CT head/C-spine/torso shwoed injuries c/w C4 pedicle fx, T12/L1 compression fxs T12 spinous process fractures. also R clavicular fx R pareital subgaleal hematoma well multiple skin soft tissue injuries Neurosurgery consulted evaluation spinal injuries recommended C-spine immobilization w/ logroll precautions place, order TLSO brace MRI C& L-spine w/n 48h assess ligamentous injury. . VS prior xfer: Afebrile, 118 114/85 24 92% 450/24/100/14peep . [Name (NI) 10115] pt intubated sedated, following commands propofol [Name8 (MD) ] RN awake answering questions appropriately propofol bolus given. Per patient's wife process getting divorced him, multiple suicide attempts past one them. 1st 2 prior attempts narcotics overdoses 3rd antifreeze ingestion. apparantly suicidal ideation since [2124-10-3] exhibited markedly worsened depressive behaviour past weeks lost job filed bankruptcy. Per wife, recently meting attorney declare bankruptcy sell house. wife told wanted get separated recently looked rooms move into. believes may precipitated recent suicide attempt. . ROS otherwise negative Past Medical History: -COPD -CHF -dementia -depression Social History: Used work State House [Location (un) ] [State 350]. unemployed, sleeps [1-19] h/day. lives home w/ wife [Name (NI) ] married past 20 years, rheir 14 y/o son [Name (NI) 43984]. Also 2 children previous marriage, ages 30 32, 6 month old grand-daughter. +smoking history, heavy EtOH prescription narcotic abuse past. Past suicide attempts. Family History: Non-contributory Physical Exam: ADMISSION EXAM: VS: afebrile, 107 110/78 24 94% AC settings GEN: intubated, sedated, currently following commands setting received propofol bolus HEENT: C-collar place, pt multiple scattered facial excoriations ecchhymoses, pupils constricted reactive b/l CV: tachycardic rate, murmurs appreciated LUNGS: anteriorly ABD: +BS obese soft ND GU: multiple scattered violaceous scrotal petechiae EXT: L-olecranon process ecchymoses skin breakdown fresh blood, R-olecranon process ecchymoses SKIN: R-hip/buttocks area large ecchymoses w/ skin breakdown NEURO: intubated, sedated, following commands . DISCHARGE EXAM: patient made Comfort Measures expired Pertinent Results: ADMISSION LABS: [2126-3-22] 02:25AM BLOOD WBC-21.1* RBC-4.68 Hgb-15.5 Hct-46.6 MCV-100* MCH-33.0* MCHC-33.2 RDW-13.6 Plt Ct-226 [2126-3-22] 02:25AM BLOOD Neuts-57.9 Lymphs-37.5 Monos-3.1 Eos-0.7 Baso-0.8 [2126-3-22] 02:25AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0 [2126-3-22] 02:25AM BLOOD Glucose-138* UreaN-38* Creat-2.4* Na-142 K-4.5 Cl-97 HCO3-35* AnGap-15 [2126-3-22] 02:25AM BLOOD ALT-20 AST-32 AlkPhos-131* TotBili-0.2 [2126-3-22] 09:08AM BLOOD Albumin-4.2 Calcium-9.0 Phos-4.2 Mg-2.3 [2126-3-22] 09:53AM BLOOD Lactate-1.1 . DISCHARGE LABS: patient expired ................................................................ MICROBIOLOGY: c diff positive ................................................................ IMAGING: [2126-3-22] CXR: lungs low volume show bilateral interstitial opacities. cardiac silhouette enlarged. mediastinal silhouette hilar contours normal. pleural effusions present. . [2126-3-22] CT Head w/o con: Right subgaleal vertex hematoma. intracranial hemorrhage. . [2126-3-22] CT C-Spine w/o con: 1. Left left superior articular facet fracture C4. 2. small amount air noted along PLL C5 likely related degenerative disc disease. disc osteophyte complexes C4/5 C6/7. 3. Retrolisthesis C4 C5. . [2126-3-22] CT Chest/Abd/Pelvis w/o con: 1. Compression fractures T12 L1 vertebral bodies fracture T12 spinous process described above. 2. Fracture right distal clavicle (features consistent chronic finding). 3. Ground-glass opacities right upper middle lobes atelectasis consolidation right lower lobe could represent sequelae aspiration pneumonia. However, given history trauma, pulmonary hemorrhage cannot excluded. . [2126-3-23] TTE: left ventricle well seen. Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. Overall left ventricular systolic function normal (LVEF>55%). aortic root mildly dilated sinus level. aortic valve stenosis. aortic regurgitation seen. mitral valve leaflets mildly thickened. Trivial mitral regurgitation seen. estimated pulmonary artery systolic pressure normal. IMPRESSION: suboptimal image quality due patient's body habitus. Left ventricular systolic function probably normal, focal wall motion abnormality cannot fully excluded. right ventricle well seen. significant valvular abnormality seen. . [2126-3-23] MRI Spine: 1. Mild moderate compressions superior endplate T12 L1 without retropulsion spinal stenosis. 2. Multilevel degenerative changes. Moderate spinal stenosis seen L4-5 level mild-to-moderate spinal stenosis seen L3-4 level. Bilateral spondylolysis L5 grade 1 spondylolisthesis L5 S1 foraminal narrowing. . [2126-3-28] RUE U/S: 1. Superficial thrombophlebitis involving right cephalic vein. 2. evidence deep venous thrombosis within right subclavian, axillary, brachial veins. Brief Hospital Course: 60M w/ COPD, CHF, s/p mechanical fall flight stairs w/ multiple spinous fx, subgaleal hematoma, difficult intubation respiratory failure c/b aspiration event. . # RESPIRATORY FAILURE/ASPIRATION: Patient primarily hypercarbic respiratory failure w/ primary respiratory acidosis pH 7.22 PCO2 83 PO2 136 also oxygenation failure ABG 100% FiO2 indicates high A-a gradient. Patient end-stage COPD likely PCO2 60s. Acute precipitant respiratory failure likely toxic ingestion superimposed underlying severe lung disease. Upon DL intubation, gross food particles evident airway, thick olive paste secretions NG. Marked leukocytosis 27.3. started ceftriaxone flagyl presumed aspiration pneumonia. Sputum cultures grew GPCs, started vancomycin flagyl discontinued. eventually switched vancomycin cefepime, eventually concluded 7 day course. Unfortunately, developed ARDS could successfully weaned ventilator settings. family meeting held, decision made make patient comfort measures (he originally DNR, DNI). terminally extubated expired [2126-4-6] 4:15pm. medical examiner accepted case review. . # FEVERS: temperature started spike HD #2. antiobiotics broadened repeatedly pan-cultured. these, found c diff + stool. treated oral vancomycin iv flagyl. continued periodically spike fevers course stay, spite treatment antibiotics. eventually made CMO terminally extubated. . # SPINAL TRAUMA: T12 L1 compression fractures fracture T12 spinous process well Left pedicle fracture C4 w/ retrolisthesis C4 C5. Neurosurgery evalutated patient, surgical intervention. [Location (un) 2848] J collar applied TLSO brace applied whenever >30. . # ATRIAL FIBRILLATION: episodes atrial fibrillation RVR hospital stay generally well controlled diltiazem. . # ATTEMPTED SUICIDE: Unclear medications patient took clearly suicide attempt. U tox negative. Patient history multiple past suicide attempts increasingly depressed recently. Intent set psychiatry, social work, however patient made CMO expired. . # HYPERKALEMIA: newly hyperkalemic upon presentation 6.2, likely secondary acute kidney injury. EKG done w/no evidence cardiac dysfunction. resolved resuscitation. . patient maintained ppi Gi prophylaxis, pneumoboots subcutaneous heparin hospital. given tube feedings nutrition. Eventually, decision made health care proxy entire family extensive family meeting make patient comfort measures only. terminally extubated, made comfortable scopolamine fentanyl. expired [2126-4-6] 4:15pm. medical examiner contact[Name (NI) ] given death involved trauma possible suicide attempt. accepted case review. Medications Admission: amlodipine 10mg daily lasix 40mg daily lexapro 20mg daily metoprolol 50mg daily lamotrigine 100mg [Hospital1 ] ventolin inhaler symbicort inhaler spiriva inhaler Discharge Medications: applicable Discharge Disposition: Expired Discharge Diagnosis: hypoxia, respiratory failure, chronic obstructive pulmonary disease, status post fall Discharge Condition: Expired Discharge Instructions: applicable Followup Instructions: applicable [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 8405]	[ "5849", "4280", "2859" ]
Admission Date: [2111-3-15] Discharge Date: [2111-3-22] Service: [Doctor Last Name 1181] HISTORY PRESENT ILLNESS: [Age 90 ]-year-old female history restrictive lung disease, diastolic congestive heart failure, atrial fibrillation, obstructive sleep apnea developed upper respiratory symptoms two days prior admission. Mildly productive cough. fevers, chills. pain. shortness breath. nausea, vomiting. dysuria. pharyngitis. stiff neck. headache. apparently lethargic approximately three days. day admission patient's daughter spoke phone noticed extremely lethargic falling asleep phone speaking her. Patient's daughter called 9-1-1 emergency medical services found patient oriented times three oxygen saturations 50% room air. Emergency Department patient's O2 sats 84% 6 liters nonrebreather mask. Chest x-ray revealed right lower lobe infiltrate. given Albuterol nebulizers times two, Solu-Medrol 125 times one, Rocephin 1 gram intravenously times one, Clindamycin 600 mg intravenously times one, subsequently transferred Medical Intensive Care Unit noninvasive ventilation. Medical Intensive Care Unit patient placed continuous positive air pressure improved oxygenation CO2 exchange. treated Azithromycin Ceftriaxone pneumonia. additionally given Albuterol Atrovent inhalers improve pulmonary function given Lasix diuresis patient mildly overloaded chest x-ray. Code discussed made "Do Resuscitate"/ "Do Intubate." subsequently called floor. PAST MEDICAL HISTORY: 1. Restrictive lung disease. 2. Pulmonary function tests [12/2110]: FVC 0.75, 38% predicted; FEV1 0.55, 46% predicted; FEV1/FVC 73, 120% predicted. 3. Congestive heart failure: Reported diastolic dysfunction. Echo [4-/2109]: Left atrium mildly dilated, left ventricular hypertrophy, left ejection fraction 55%, right ventricle dilated, signs aortic stenosis, mild 1+ mitral regurgitation, moderate pulmonary hypertension, trace pericardial effusion. 4. Atrial fibrillation. 5. Hypertension. 6. Obstructive sleep apnea. 7. Lacunar infarcts. 8. Spinal stenosis. 9. Grave's disease. 10. Hypothyroidism. 11. Right breast cancer status post XRT. 12. Cerebrovascular accident [2101] left eye visual disturbance. 13. Left cataract surgery. 14. Total abdominal hysterectomy secondary fibroids. 15. Cholecystectomy. 16. PFO. 17. Scoliosis. SOCIAL HISTORY: Patient widow, two children, lives daughter. Denies alcohol. 100-pack-year history tobacco. Worked bookkeeper past. FAMILY HISTORY: Three siblings died heart attacks. Father died CVA. Mother died 60s hypertension renal dysfunction. MEDICATIONS HOME: 1. Colace. 2. Coumadin 5 mg alternating 7.5 mg mouth every day. 3. Salmeterol. 4. Diltiazem 30 mg mouth twice per day. 5. Furosemide needed. 6. Nifedipine 30 mg p.o. evening. 7. Folic acid 1 mg q. day. 8. Multivitamin one q. day. 9. Levothyroxine 100 mcg q. day. 10. Aspirin. 11. Isosorbide dinitrate 20 mg t.i.d. PHYSICAL EXAMINATION: Vital signs: Temperature 97.6, pulse 76, blood pressure 136/54, respirations 21, satting 89% 4 liters nasal cannula. General: irritable difficult, elderly, disheveled female; compliant exam. EENT: Extraocular movements intact; pupils equal reactive light; dentures appreciated; mucous membranes moist. Jugular venous distention approximately 7 8 cm. Neck: Supple without masses thyromegaly; lymphadenopathy appreciated. Cardiovascular: Regular rate rhythm; laterally displaced point maximal impulse; prominent S1 greater S2; murmurs, rubs, gallops. Pulmonary: Bibasilar crackles wheezes diffusely throughout lung fields; breath sounds decreased bases bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended; hepatosplenomegaly, masses, bruits. Extremities: clubbing, cyanosis, edema; 2+ dorsalis pedal posterior tibial pulses bilaterally. Skin: Multiple skin tags actinic keratoses back; rashes bruises. Neuro: Motor [6-3] extremities. Sensation generally intact light touch. Reflexes, patellar, brachioradialis 1+ bilaterally. Cranial nerves II-XII grossly intact. LABORATORY STUDIES ADMISSION: ABG 7.29/83/95 CPAP. Chem-7: Sodium 141, potassium 4.1, chloride 105, bicarbonate 27, BUN 30, creatinine 0.9, glucose 152, white blood count 8.3, hematocrit 36, platelets 152, INR 2.3, troponin 0.07. Urinalysis within normal limits. chest x-ray showed right lower lobe infiltrate cardiomegaly. Chest x-ray done [2111-3-15] showed right lower lobe pneumonia, mild cardiac failure, left pleural effusion. Chest x-ray [2111-3-16] showed slight improvement right lower lobe consolidation, improving left retrocardiac opacity, slight decrease left pleural effusion. Chest x-ray [2111-3-17] showed progression right upper lobe opacity; stable right lower lobe left lower lobe consolidation; improving left pleural effusion; persistent uppers vascular redistribution. CONCISE SUMMARY HOSPITAL COURSE: 1. Hypercarbic respiratory failure: Ms. [Known lastname 32729] admitted directly Medical Intensive Care Unit management hypercarbic respiratory failure noninvasive ventilation. chronic CO2 retainer ranging 50s 110s CO2. Serial arterial blood gases checked monitor progress. initial presentation Chem-7 ABG consistent respiratory acidosis without metabolic compensation hypoxia. anion gap. started Solu-Medrol 100 mg t.i.d., changed Prednisone 60 mg q. day upon discharge floor. patient initially improving BiPAP noted ABGs. However, tolerate BIPAP refused continue it. agreement made patient team keep face mask nasal cannula periods BiPAP. remainder MICU stay. started antibiotics MICU treatment pneumonia. used Rocephin Azithromycin treat community-acquired pneumonia. likely development pneumonia may cause hypercarbic respiratory failure. addition, patient noted somewhat volume overloaded subsequent exams MICU also noted congestion chest x-ray. started Lasix 20 mg intravenously b.i.d. MICU assist diuresis resolution pulmonary edema. Patient transferred floor continued refuse BiPAP CPAP assistance. Patient additionally refused antibiotic medications last day MICU stay called floor. hospital day five. Team, nursing, Attending meeting patient address refusal oxygen medication management. Patient convinced keep oxygen 2 liters throughout remainder stay also agreed continue taking medications improve pneumonia. Repeat chest x-rays showed improvement pneumonia pulmonary congestion. Whenever patient oxygen patient would episodes agitation confusion. Prior discharge patient's mentation sensorium improved, pneumonia treatment, volume overload significantly improved. 2. Diastolic dysfunction: Patient noted pulmonary edema volume overloaded exam elevated jugulovenous pressure subsequent exams MICU. Patient started 20 mg intravenous Lasix b.i.d. euvolemic. Euvolemia assessed measuring JVP, serial weights, monitoring daily input output. Patient euvolemic prior discharge. 3. Right lower lobe pneumonia: Patient treated community-acquired pneumonia Azithromycin Rocephin. hospital day five admission patient refused two three doses antibiotics likely secondary confusion, agitation patient oxygen quite time. Meeting held patient, team, Attending, nurse convince comply treatment goals. agreed continue taking medications keeping oxygen thanks Dr.[Name (NI) 9920] persuasion. Pneumonia treatment prior discharge. Repeat chest x-rays showed improvement pneumonia. 4. History atrial fibrillation: Patient continued Diltiazem throughout remainder hospital course. normal sinus throughout hospital stay. patient continued Coumadin INR goal 2 2.5. Patient taken Coumadin hospital day three hospital day five noted supertherapeutic INR. Coumadin reinstituted two days prior discharge discharged therapeutic INR. 5. Obstructive sleep apnea: CPAP attempted; however, patient refused on. CPAP well tolerated patient throughout remainder hospital course. Agreed two liter nasal cannula times. 6. Endocrine: Hypothyroidism: Patient continued outpatient dose Synthroid. Hyperglycemia: patient placed regular insulin sliding scale time steroids. Steroids stopped patient hospital day five, allowing taper. Ultimately, regular sliding scale discontinued two days prior discharge since good blood glucose levels within normal range. 7. Code: Long discussion held patient daughter Dr. [Last Name (STitle) ]. Patient agreed "Do Resuscitate"/"Do Intubate" made comfortable sick. However, sign Comfort Measures form reluctant discuss [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 1764]. discussion arranged Dr. [Last Name (STitle) ] subsequent office visits. is, however, DNR/DNI. 8. Acute renal failure: Patient noted acute renal failure MICU course. However, discharged floor patient's renal failure resolved. peak creatinine 1.3 creatinine prior discharge 1.0. DISCHARGE CONDITION: Fair. DISPOSITION: home VNA services; discussions held subsequent visits Dr. [Last Name (STitle) ] regarding Hospice care. DISCHARGE DIAGNOSES: 1. Hypercarbic respiratory failure. 2. Pneumonia. 3. Alkalemia. 4. Thrombocytopenia. 5. Hypertension. 6. Hypothyroidism. 7. Diastolic heart failure. 8. Obstructive sleep apnea. 9. Restrictive lung disease. 10. Acute renal failure. DISCHARGE MEDICATIONS: 1. Fluticasone. 2. Salmeterol 250 50 mcg, one puff b.i.d. 3. Diltiazem 30 mg tablets, one tablet p.o. b.i.d. 4. Furosemide 50 mg tablet, one tablet p.o. q. day. 5. Nifedipine 30 mg tablet, Sustained Release, one tablet p.o. q. h.s. 6. Aspirin 81 mg tablet, one tablet p.o. q.d. 7. Folic acid 1 mg tablet, one tablet p.o. q. day. 8. Synthroid 100 mcg tablet, one tablet, p.o. q. day. 9. Multivitamin, one capsule q. day. 10. Colace 100 mg, one capsule p.o. b.i.d. 11. Isosorbide dinitrate 10 mg, one tablet p.o. t.i.d. 12. Levofloxacin 250 mg tablets, one tablet p.o. q. 24 times five days. DISCHARGE INSTRUCTIONS: 1. Patient follow Dr. [Last Name (STitle) ] one two weeks. Patient call schedule appointment ([Telephone/Fax (1) 102295]). 2. Patient follow Clinical Center Radiology mammography done [2111-11-16] 10 a.m. call [Telephone/Fax (1) 327]. [Name6 (MD) ] [Last Name (NamePattern4) 5467], M.D. [MD Number(1) 5468] Dictated By:[Last Name (NamePattern1) 9622] MEDQUIST36 D: [2111-5-23] 15:17 T: [2111-5-23] 21:36 JOB#: [Job Number 102296]	[ "486", "5849", "4280", "4019" ]
Admission Date: [2162-3-29] Discharge Date: [2162-4-19] Date Birth: [2075-12-17] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: shortness breath Major Surgical Invasive Procedure: 1. Intubation mechanical ventilation. 2. Placement 2 pleurex catheters History Present Illness: 86F history DM2, HTN, HLD, cardiac problem, transferred [Name (NI) ]. Pt presented one month breathing difficulty, weight loss, cough, decreased apetite getting progressively worse time. Family trie bring pt earlier refused go hospital. Last night pt became acute SOB family called ambulance pt brought [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [Hospital1 ] found WBC 44, HR 170's fib, lactate=4; concern possible malignant process ? PE. Got dilt 30mg PO 10mg IV HR, improved. Also got 4L IVF. LENI showed R DVT. Got head CT showed nothing acute. Deferred CTA chest due elevated Cr (Cr 1.8). Started heparin gtt DVT concern PE. Got azithro ceftriaxone [Hospital1 ]. transport pt developed worsened rales/crackles possibly secondary 4 L IVF given. . [Hospital1 18] ED, initial VS were: 65, RR 32, 128/59, 97% 15L NRB. ECG showed AFib RVR. Patient started nitro gtt, heparin gtt, given vancomycin/zosyn, placed BiPAP resp distress didnt tolerate. Labs notable lactate 8.5, WBC count 49.3, INR 1.6 Cr 1.8. CXR: air fluid level abscess lung. Patient initially trialed BiPAP, tolerate, thus intubated (straight forward intubation). Placed R IJ. CVP=13. Lactate rose 10 concern gut ischemia. CTA chest torso: PE, revealed multiple abscess L lung- Rim enhancing fluid collection. Multiple hypodensisities kidney liver suggestive embolic infectious process. ED given: Vanco, zosyn, flagyl. Thoracics consult: Poor surgical candidate. Recc drainage per IR right now. K=6-->insulin/D50, Kayexlate. Gave 1 UPRBC elevated lactate. ED attempted call family several times give update, never got through. . arrival MICU, pt intubated, sedated, Levo 0.2 Dopamine 8. family meeting son 3 grandchildren. Family tearful, request FULL code continue discuss goals care. report pt usualy active baseline, ambulatory, takes care great grandchildren. Past Medical History: Dm2 HTN HLD Cardiac process- seen [Hospital 1263] hospital, family sure process is. Social History: Lives son, normally active baseline babysits grandchildren. Ambulatory. Rarely admitted hospital. history smoking drug use. Family History: cancers. Physical Exam: Vitals:T 98.1, HR 83, BP 110/51, fib, 98% AC FiO2 40, TV 350, F 20, PEEP 5, MV 8.2. IVF in: 6L plus 1 PRBC. UO: 230 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] 180 [Hospital1 18] ED. General: sedated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated, LAD CV: irregular rate, mrg. Lungs: anterior breath sounds, crackles, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: sedated Pertinent Results: Cytology [2162-3-29] NEGATIVE MALIGNANT CELLS. Acellular specimen bacterial overgrowth; Correlate microbiology report. ECG Study Date [2162-3-29] 2:29:44 rhythm regular likely junctional escape rhythm 60 beats per minute without clear atrial activity. Delayed R wave transition. previous tracing available comparison. Possible prior anteroseptal myocardial infarction. CHEST (PORTABLE AP) Study Date [2162-3-29] 2:45 FINDINGS: extensive opacification left hemithorax air-fluid level identified superiorly. findings representative large mass, possibly abscess fissure. Less likely would large hiatal hernia. rightward shift normally midline structures. Otherwise, right hemithorax appears clear. acute fractures identified. dedicated chest CT recommended evaluation Portable TTE (Complete) Done [2162-3-29] 12:03:01 PM FINAL left atrium elongated. thrombus/mass seen body left atrium. right atrium markedly dilated. atrial septal defect seen 2D color Doppler. estimated right atrial pressure least 15 mmHg. Left ventricular wall thicknesses normal. left ventricular cavity unusually small. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). masses thrombi seen left ventricle. ventricular septal defect. right ventricular free wall hypertrophied. right ventricular cavity mildly dilated normal free wall contractility. abnormal diastolic septal motion/position consistent right ventricular volume overload. ascending aorta mildly dilated. aortic valve leaflets (3) mildly thickened aortic stenosis present. masses vegetations seen aortic valve. aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. mass vegetation seen mitral valve. Mild (1+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. Moderate [2+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. vegetation/mass seen pulmonic valve. Significant pulmonic regurgitation seen. trivial/physiologic pericardial effusion. echocardiographic signs tamponade CT ABD & PELVIS CONTRAST Study Date [2162-3-29] 3:05 IMPRESSION: 1. Multilobulated large left hemithorax pleural empyema foci gas noted. Given foci gas differential includes recent instrumentation versus infection gas-forming organism versus bronchopleural fistula. 2. Multiple hypodense areas also visualized throughout bilateral nonenlarged kidneys. findings may representative multiple cysts superinfectious process multiple abscesses cannot excluded. 3. Small subsegmental right upper lobe pulmonary emboli. 4. mild gallbladder wall edema mottled apparance liver likely due congestive hepatopathy. 5. Endotracheal tube tip level carina. Retraction 2cm recommended. 6. Bilateral small pleural effusions. 7 . Severe cardiomegaly. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date [2162-3-29] 3:05 IMPRESSION: 1. Multilobulated large left hemithorax pleural empyema foci gas noted. Given foci gas differential includes recent instrumentation versus infection gas-forming organism versus bronchopleural fistula. 2. Multiple hypodense areas also visualized throughout bilateral nonenlarged kidneys. findings may representative multiple cysts superinfectious process multiple abscesses cannot excluded. 3. Small subsegmental right upper lobe pulmonary emboli. 4. mild gallbladder wall edema mottled apparance liver likely due congestive hepatopathy. 5. Endotracheal tube tip level carina. Retraction 2cm recommended. 6. Bilateral small pleural effusions. 7 . Severe cardiomegaly. Multiple CXR performed, representative reads shown. CHEST (PORTABLE AP) Study Date [2162-3-31] 2:17 FINDINGS: left pigtail catheter unchanged position. right IJ ET tubes terminate standard position. NG tube terminates outside field view. Compared [3-30], increasing bilateral pleural effusions, pulmonary vascular congestion, parenchymal opacities suggesting developing pulmonary edema. Cardiomegaly unchanged. Tere pneumothorax. Findings discussed Dr. [Last Name (STitle) ] Dr. [Last Name (STitle) ] phone 11:45 a.m. [2162-3-31]. CT CHEST W/O CONTRAST Study Date [2162-3-31] 9:08 IMPRESSION: Interval resolution dominant gas/fluid collection within left hemithorax, near-resolution adjacent medial collection. remains loculated posterior collection appear tocommunicate catheter. 2. Adjacent severe left lower lobe atelectasis consolidative component. Slightly enlarged small right pleural effusion. Trace pericardial effusion. New moderate anasarca. Increased caliber main pulmonary artery likely reflects chronic pulmonary hypertension. . CT Torso [4-4] IMPRESSION: 1. Reaccumulation left sided localized hydropneumothorax s/p pigtail catheter removal. 2. Bilateral peribronchial ground glass opacity patchy opacities non-specific finding. 3. Slight decrease size right pleural effusion. 4. Stable increased diameter main pulmonary artery likely due pulmonary hypertension. 5. Persistent non-mobile 1.3cm filling defect within left main bronchus suspicious polyp, neoplasm mucus plug. . CT Chest [4-6] IMPRESSION: 1. Mid-esophageal soft tissue mass severly narrows may invade left main bronchus. 2. Interval placement second left lower lung drain interval decrease size air fluid collection. Persistent left lower lung consolidation either pneumonia atelectasis. 3. Markedly enlarged right atrium. 4. Thinning renal cortices hyperdensity could represent retained contrast nephrocalcinosis. . ECHO [4-6] left atrium elongated. right atrium markedly dilated. atrial septal defect seen 2D color Doppler. estimated right atrial pressure 5-10 mmHg. mild symmetric left ventricular hypertrophy normal cavity size regional/global systolic function (LVEF>55%). ventricular septal defect. borderline normal free wall function. abnormal septal motion/position consistent right ventricular pressure/volume overload. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. masses vegetations seen aortic valve. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. mass vegetation seen mitral valve. eccentric, posteriorly directed jet mild (1+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. Moderate severe [3+] tricuspid regurgitation seen. severe pulmonary artery systolic hypertension. small pericardial effusion. effusion echo dense, consistent blood, inflammation cellular elements. Compared prior study (images reviewed) [2162-3-29], degree TR pulmonary hypertension increased. .. INDICATIONS: 86-year-old female esophageal cancer, lung empyema ischemic right foot. Bilateral lower extremity ABIs, Doppler waveforms, PVRs performed rest. FINDINGS: RIGHT: right ABI 0.65 DP. signal present PT. Doppler waveforms biphasic level popliteal artery. Posterior tibial waveform absent. dorsalis pedis waveform monophasic. PVRs artifactually diminished proximally aphasic metatarsal level suggesting severe tibial disease. left ABI 0.61 DP. PT waveform absent. Left-sided Doppler waveforms triphasic popliteal level monophasic dorsalis pedis. PVRs show significant dropoff calf ankle ankle metatarsal level suggesting severe tibial occlusive disease. IMPRESSION: ABIs likely falsely elevated. Based Doppler waveforms PVRs, severe tibial disease bilaterally. . COMPARISON: CT [4-4] [2162-4-6]. TECHNIQUE: MDCT data acquired chest without intravenous contrast. Images displayed multiple planes. FINDINGS: two pigtail catheters left lung base. small-to-moderate effusion layers posteriorly. large air-fluid collection communication anterior posterior drain. Moderate left basilar atelectasis and/or consolidation unchanged. moderate right effusion slightly larger. new consolidation, nodule, pneumothorax present. Since prior exam, esophageal catheter removed. boundaries large mid esophageal mass hard delineate without contrast. lesion measures approximately 1.9 x 3.4 cm (2:20). Since preceding exam five days ago, left main bronchus become completely effaced (2:20) combination mass effect thickened esophagus, bronchial secretions. extensive secretions distal left lower lobe segmental bronchus (2:25). tracheo-esophageal connection directly visualized would suprising given appearence. non-contrast appearance heart great vessels shows cardiomegaly, massive right atrial enlargment, minimal aortic arch calcification. tip right subclavian line terminates low SVC. thyroid normal attenuation. mesenteric, hilar axillary adenopathy present. residual renal excretion contrast [3-29]. peripheral hyperdense foci visualized portions kidneys. Previously, cortices kidneys uniformly hyperdense. Residual oral contrast seen nondistended loops large bowel. BONES SOFT TISSUES: concerning lytic sclerotic lesions. Bilateral lower old rib fractures. diffuse soft tissue edema. IMPRESSION: 1. Large mid esophageal soft tissue mass complete opacification left main bronchus either invasion, hemorrhage, and/or secretions. Persistent post-obstructive left lower lobe consolidation bronchial secretions. 2. Improving small-to-moderate left pleural effusion. large collection site two pigtail catheters. 3. Increasing moderate right effusion. 4. Stable right atrial enlargement. Final Report CHEST RADIOGRAPH INDICATION: Query pneumothorax, 86-year-old woman large esophageal neoplasm extending left mainstem. TECHNIQUE: Portable upright chest view read comparison multiple prior radiographs recent [2162-4-13]. FINDINGS: Lower lung opacity due combination effusion atelectasis involves entire left hemithorax suggestive increased large left pleural effusion. Two pleural pigtail catheters left lower hemithorax unchanged position. Increase left pleural effusion. much change position mediastinum probably due associated left lung volume loss. Moderate right pleural effusion right basilar atelectasis similar. Upper lung clear. IMPRESSION: Left pleural effusion progressed last two days. Two left pleural pigtail catheters unchanged position moderate right pleural effusion bibasilar atelectasis unchanged. study report reviewed staff radiologist. Microbiology: [2162-4-15] 8:12 pm URINE Source: Catheter. FINAL REPORT [2162-4-16] URINE CULTURE (Final [2162-4-16]): GROWTH. [2162-4-5] 6:36 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [2162-4-5]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. FLUID CULTURE (Final [2162-4-8]): GROWTH. ANAEROBIC CULTURE (Final [2162-4-11]): GROWTH. FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. ACID FAST SMEAR (Final [2162-4-6]): ACID FAST BACILLI SEEN DIRECT SMEAR. ACID FAST CULTURE (Preliminary): MYCOBACTERIA ISOLATED. [2162-3-29] 4:40 pm FLUID RECEIVED BLOOD CULTURE BOTTLES Site: PLEURAL FINAL REPORT [2162-4-2] Fluid Culture Bottles (Final [2162-4-2]): GRAM NEGATIVE ROD(S). REFER SPECIME # 343-4776A [2162-3-29]. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SENSITIVITIES PERFORMED CULTURE # 343-4776A [2162-3-29]. GRAM POSITIVE RODS. REFER SPECIMEN # 343-4776A [2162-3-29]. Anaerobic Bottle Gram Stain (Final [2162-3-29]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI PAIRS CHAINS. GRAM POSITIVE ROD(S). Reported read back [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27395] [2162-3-29] @ 740 PM. Aerobic Bottle Gram Stain (Final [2162-3-29]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI PAIRS CHAINS. GRAM POSITIVE ROD(S). [2162-3-29] 3:30 BLOOD CULTURE # 2. FINAL REPORT [2162-4-4] Blood Culture, Routine (Final [2162-4-4]): GROWTH. [2162-4-16] 04:08AM BLOOD WBC-11.3* RBC-3.46* Hgb-10.0* Hct-33.9* MCV-98 MCH-28.9 MCHC-29.6* RDW-22.8* Plt Ct-270 [2162-4-15] 03:04AM BLOOD WBC-11.2* RBC-3.57* Hgb-10.2* Hct-34.7* MCV-97 MCH-28.5 MCHC-29.3* RDW-22.6* Plt Ct-286 [2162-4-14] 05:06AM BLOOD WBC-8.9 RBC-3.28* Hgb-9.3* Hct-33.9* MCV-103* MCH-28.3 MCHC-27.3* RDW-23.0* Plt Ct-262 [2162-4-12] 03:03PM BLOOD WBC-10.5 RBC-3.60* Hgb-10.1* Hct-33.0* MCV-91 MCH-28.1 MCHC-30.7* RDW-22.6* Plt Ct-304 [2162-4-12] 06:00AM BLOOD WBC-10.4 RBC-3.71* Hgb-10.6* Hct-34.8* MCV-94 MCH-28.5 MCHC-30.4* RDW-23.1* Plt Ct-299 [2162-4-10] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292 [2162-4-11] 03:42AM BLOOD WBC-11.6* RBC-3.78* Hgb-10.4* Hct-34.4* MCV-91 MCH-27.4 MCHC-30.1* RDW-22.6* Plt Ct-305 [2162-4-10] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292 [2162-4-9] 02:57AM BLOOD WBC-14.2* RBC-3.62* Hgb-10.1* Hct-33.7* MCV-93 MCH-28.0 MCHC-30.1* RDW-23.5* Plt Ct-265 [2162-4-8] 03:48AM BLOOD WBC-20.4* RBC-3.62* Hgb-10.3* Hct-32.8* MCV-91 MCH-28.5 MCHC-31.4 RDW-22.2* Plt Ct-247 [2162-4-7] 02:27AM BLOOD WBC-22.8* RBC-3.41* Hgb-9.6* Hct-30.1* MCV-88 MCH-28.1 MCHC-31.8 RDW-19.8* Plt Ct-226 [2162-4-6] 02:20AM BLOOD WBC-23.5* RBC-3.86* Hgb-10.9* Hct-35.7* MCV-93 MCH-28.2 MCHC-30.5* RDW-19.6* Plt Ct-206 [2162-4-5] 01:57AM BLOOD WBC-20.3* RBC-3.76* Hgb-10.6* Hct-34.2* MCV-91 MCH-28.1 MCHC-30.9* RDW-19.2* Plt Ct-180 [2162-4-4] 03:04AM BLOOD WBC-22.3* RBC-3.85* Hgb-10.7* Hct-34.7* MCV-90 MCH-27.7 MCHC-30.7* RDW-18.6* Plt Ct-165 [2162-4-3] 02:56AM BLOOD WBC-27.4* RBC-3.94* Hgb-11.4* Hct-35.6* MCV-90 MCH-29.0 MCHC-32.1 RDW-17.7* Plt Ct-175 [2162-4-2] 03:22AM BLOOD WBC-24.2* RBC-4.21 Hgb-11.7* Hct-38.3 MCV-91 MCH-27.8 MCHC-30.5* RDW-17.4* Plt Ct-204 [2162-4-1] 03:34AM BLOOD WBC-24.2* RBC-3.99* Hgb-11.2* Hct-35.4* MCV-89 MCH-28.2 MCHC-31.8 RDW-17.6* Plt Ct-212 [2162-3-31] 01:10PM BLOOD WBC-27.0* RBC-4.15* Hgb-11.4* Hct-37.2 MCV-90 MCH-27.4 MCHC-30.6* RDW-16.8* Plt Ct-310 [2162-3-31] 04:24AM BLOOD WBC-24.9* RBC-3.96* Hgb-11.0* Hct-34.9* MCV-88 MCH-27.8 MCHC-31.6 RDW-17.2* Plt Ct-264 [2162-3-30] 11:17PM BLOOD WBC-23.3* RBC-3.85* Hgb-10.3* Hct-33.1* MCV-86 MCH-26.8* MCHC-31.2 RDW-16.3* Plt Ct-288 [2162-3-30] 07:07PM BLOOD WBC-28.8* RBC-3.31* Hgb-9.3* Hct-28.8* MCV-87 MCH-28.0 MCHC-32.3 RDW-16.0* Plt Ct-408 [2162-3-29] 11:58PM BLOOD WBC-36.1* RBC-4.10* Hgb-11.0* Hct-36.1 MCV-88 MCH-26.7* MCHC-30.3* RDW-15.9* Plt Ct-425 [2162-3-29] 01:37PM BLOOD WBC-48.5* RBC-3.99* Hgb-10.5* Hct-35.7* MCV-90 MCH-26.3* MCHC-29.3* RDW-15.4 Plt Ct-541* [2162-3-29] 10:41AM BLOOD WBC-46.5* RBC-3.79* Hgb-9.8* Hct-34.3* MCV-91 MCH-25.9* MCHC-28.6* RDW-15.0 Plt Ct-501* [2162-3-29] 08:20AM BLOOD WBC-44.7* RBC-3.74* Hgb-9.9* Hct-34.6* MCV-93 MCH-26.5* MCHC-28.7* RDW-15.0 Plt Ct-514* [2162-3-29] 02:45AM BLOOD WBC-49.3* RBC-3.71* Hgb-9.7* Hct-33.7* MCV-91 MCH-26.2* MCHC-28.8* RDW-15.2 Plt Ct-589* [2162-3-29] 02:45AM BLOOD Neuts-85* Bands-3 Lymphs-4* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2162-3-29] 08:20AM BLOOD Neuts-95.9* Lymphs-2.5* Monos-1.2* Eos-0 Baso-0.4 [2162-4-1] 03:34AM BLOOD Neuts-90.9* Lymphs-8.1* Monos-0.5* Eos-0.2 Baso-0.2 [2162-4-2] 03:22AM BLOOD Neuts-93.0* Lymphs-5.2* Monos-1.0* Eos-0.2 Baso-0.6 [2162-4-16] 04:08AM BLOOD PT-15.7* PTT-103.7* INR(PT)-1.5* [2162-4-15] 03:04AM BLOOD PT-14.4* PTT-33.5 INR(PT)-1.3* [2162-4-14] 05:06AM BLOOD PT-15.4* PTT-150* INR(PT)-1.4* [2162-4-6] 02:20AM BLOOD PT-14.4* PTT-87.4* INR(PT)-1.3* [2162-4-1] 09:30PM BLOOD PT-12.8* PTT-103* INR(PT)-1.2* [2162-4-1] 05:10PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2* [2162-3-29] 01:37PM BLOOD PT-18.0* PTT-28.7 INR(PT)-1.7* [2162-4-16] 04:08AM BLOOD Glucose-115* UreaN-32* Creat-1.4* Na-141 K-4.3 Cl-113* HCO3-25 AnGap-7* [2162-4-15] 03:04AM BLOOD Glucose-228* UreaN-33* Creat-1.4* Na-143 K-4.1 Cl-114* HCO3-25 AnGap-8 [2162-4-14] 09:52AM BLOOD Glucose-145* UreaN-34* Creat-1.5* Na-145 K-3.4 Cl-115* HCO3-24 AnGap-9 [2162-4-14] 05:06AM BLOOD Glucose-826* UreaN-30* Creat-1.5* Na-133 K-6.5* Cl-105 HCO3-21* AnGap-14 [2162-4-10] 02:59PM BLOOD Creat-1.8* Na-146* K-3.8 Cl-114* HCO3-22 AnGap-14 [2162-4-9] 02:57AM BLOOD Glucose-119* UreaN-54* Creat-2.2* Na-146* K-3.6 Cl-114* HCO3-24 AnGap-12 [2162-4-8] 03:48AM BLOOD Glucose-201* UreaN-61* Creat-2.6* Na-143 K-4.1 Cl-114* HCO3-20* AnGap-13 [2162-4-6] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139 K-4.2 Cl-106 HCO3-20* AnGap-17 [2162-4-6] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139 K-4.2 Cl-106 HCO3-20* AnGap-17 [2162-4-5] 01:57AM BLOOD Glucose-182* UreaN-51* Creat-2.7* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 [2162-4-2] 03:22AM BLOOD Glucose-146* UreaN-43* Creat-1.9* Na-143 K-3.4 Cl-113* HCO3-19* AnGap-14 [2162-3-31] 04:24AM BLOOD Glucose-208* UreaN-48* Creat-1.7* Na-139 K-3.5 Cl-111* HCO3-16* AnGap-16 [2162-3-29] 10:41AM BLOOD Glucose-128* UreaN-56* Creat-1.7* Na-142 K-4.8 Cl-112* HCO3-15* AnGap-20 [2162-3-29] 02:45AM BLOOD Glucose-141* UreaN-60* Creat-1.8* Na-138 K-6.5* Cl-109* HCO3-13* AnGap-23* [2162-4-13] 05:32AM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-0.5 [2162-4-12] 03:03PM BLOOD ALT-15 AST-18 LD(LDH)-261* Amylase-129* [2162-4-1] 03:34AM BLOOD ALT-88* AST-76* LD(LDH)-246 AlkPhos-201* TotBili-0.8 [2162-3-31] 04:24AM BLOOD ALT-119* AST-206* LD(LDH)-320* AlkPhos-116* TotBili-0.8 [2162-3-29] 10:41AM BLOOD ALT-111* AST-600* LD(LDH)-1689* AlkPhos-119* TotBili-0.6 [2162-4-12] 03:03PM BLOOD CK-MB-4 cTropnT-0.04* [2162-3-29] 01:37PM BLOOD CK-MB-4 cTropnT-0.04* [2162-3-29] 10:41AM BLOOD CK-MB-4 cTropnT-0.03* [2162-3-29] 08:20AM BLOOD cTropnT-0.03* [2162-3-29] 02:45AM BLOOD cTropnT-0.04* [2162-4-16] 04:08AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 [2162-4-15] 03:04AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0 [2162-3-29] 02:45AM BLOOD Albumin-2.3* [2162-3-29] 08:20AM BLOOD Calcium-7.0* Phos-6.6* Mg-2.1 [2162-3-29] 10:41AM BLOOD Albumin-1.8* Calcium-6.9* Phos-5.1* Mg-1.9 [2162-3-29] 01:37PM BLOOD Calcium-7.4* Phos-5.2* Mg-2.1 UricAcd-10.6* [2162-3-29] 01:37PM BLOOD Hapto-326* [2162-3-30] 10:02AM BLOOD Vanco-9.5* [2162-3-31] 06:04PM BLOOD Vanco-15.4 [2162-4-1] 07:07PM BLOOD Vanco-20.5* [2162-4-2] 08:10AM BLOOD Vanco-18.5 [2162-4-8] 05:43AM BLOOD Vanco-22.8* [2162-4-9] 05:57AM BLOOD Vanco-20.4* [2162-4-12] 06:00AM BLOOD Vanco-18.9 [2162-4-13] 05:32AM BLOOD Vanco-24.9* [2162-3-29] 02:58AM BLOOD Lactate-8.5* K-6.5* [2162-3-29] 04:44AM BLOOD Glucose-124* Lactate-9.6* K-6.2* [2162-3-29] 04:53AM BLOOD Lactate-9.3* [2162-3-29] 06:22AM BLOOD Lactate-9.6* [2162-3-29] 08:48AM BLOOD Glucose-205* Lactate-7.0* Na-139 K-5.4* Cl-113* calHCO3-13* [2162-3-29] 11:12AM BLOOD Lactate-4.7* [2162-3-29] 11:53PM BLOOD Lactate-2.9* [2162-3-30] 12:27PM BLOOD Lactate-2.7* [2162-3-31] 12:52AM BLOOD Lactate-2.2* [2162-3-31] 09:16AM BLOOD Lactate-2.7* [2162-3-31] 04:23PM BLOOD Lactate-2.4* [2162-3-31] 06:14PM BLOOD Lactate-2.1* [2162-4-1] 03:17PM BLOOD Lactate-1.7 [2162-4-2] 03:37AM BLOOD Lactate-1.5 [2162-4-4] 04:17AM BLOOD Lactate-2.1* [2162-4-6] 02:28AM BLOOD Lactate-3.8* [2162-4-6] 10:01AM BLOOD Lactate-5.4* [2162-4-6] 02:18PM BLOOD Lactate-4.4* [2162-4-14] 10:33AM BLOOD Lactate-1.7 [2162-4-5] 06:36PM PLEURAL WBC-[Numeric Identifier 110572]* RBC-[Numeric Identifier 28746]* Polys-98* Lymphs-0 Monos-1* Meso-1* [2162-4-3] 06:21PM PLEURAL WBC-1700* RBC-800* Polys-75* Lymphs-20* Monos-0 Baso-1* Meso-1* Other-3* [2162-3-29] 02:45AM estGFR-Using Brief Hospital Course: 86 yo F known medical problems admitted shortness breath cough. Hospital course notable admission ICU found lung renal abscesses, septic shock requiring vasopressor support, DVT PE, difficult control atrial fibrillation. also noted large esophageal mass suggestive esophageal cancer compression left main stem bronchus causing intermittent lung collapse esophageal compression dysphagia/aspiration. Patient long ICU course transferred floor ICU multiple times. Ultimately, given patient's multiple significant severe medical problems, age, progressively declining course despite maximal medical care, discussion held family decision transition patient's care comfort centered care patient passed away [2162-4-19] 2:10AM. #Septic shock/Lung renal abscesses: Patient presented septic shock pneumonia empyema found lung renal abscesses. required multiple pressors intubation. lactate peaked 10. CT demonstrated multiple fluid collections well esophageal mass (see below) compressing L mainstem bronchus believed predisposing polymicrobial infection. Interventional pulmonology placed two chest tubes drain fluid collections. Gram stain showed GPCs, GNRs gram positive rods. Cultures grew strep angionosis. initially treated broad spectrum antibiotics weaned vancomycin flagyl per ID recommendations planned course four weeks date last chest tube placement (day one [4-5]). weaned pressors succesfully extubated. treated vanc/flagyl made CMO [2162-4-16]. #DVT/PE: Patient found DVT lower extremity ultrasound. CTA showed small subsegmental RLL PE. Patient placed heparin gtt. goals care discussion anticoagulation held [2162-4-16]. #Esophageal Mass, likely esophageal cancer, bronchial esophageal obstruction: CT showed large mid esophageal soft tissue mass complete opacification left main bronchus either invasion, hemorrhage, and/or secretions. persistent post-obstructive left lower lobe consolidation bronchial secretions patient suffer collapse left lung. believed mass etiology polymicrobial septic shock, well persistent pleural effusions left sided atelectatsis. Secondary obstruction esophagus risks aspiratoin, patient made NPO. transiently receive TPN, discontinued care transitioned comfort centered care. #Atrial fibrillation: Unclear patient history afib, likely exacerbated caused infection/sepsis. may also contribution irritation esophageal mass. hypotension resolved patient managed medical floor IV betablockers required transfer back ICU rapid atrial fibrillation low blood pressures 90s. subsequently rate controlled IV amiodarone drip ICU transferred back medical floor. family discussion regarding overall goals care amiodarone eventually discontinued. # Acute Renal failure: Creatinine 1.8 unclear baseline. creatinine later increased peak 2.8 believed ATN septic shock. creatinine trended back 1.8. floor creatinine remained baseline. # Anemia: required 3 UPRBC setting elevated lactate septic shock. Hct stabilzed mid 30s. #Goals care discussion: Throughout hospitalization multiple family meetings/updates held multiple providers/teams. Palliative care involved social work case management teams. patient's age >80 years multiple medical problems continued progress despite medical care (including IV amiodarone drip, TPN, antibiotics, IV anticoagulation), family decided focus comfort centered care [2162-4-16]. patient passed away [2162-4-19] 2AM. Medications Admission: None Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: 1. Esophageal neoplasm 2. Septic shock 3. Atrial fibrillation 4. Deep venous thrombosis 5. Pulmonary Emboli 6. Digital necrosis [3-8] metatsarsals 7. Occlusive narrowing tibial arteries bilaterally 8. Pleural effusions 9. Pulmonary empyema Discharge Condition: expired	[ "486", "4019", "2724", "2859" ]
Admission Date: [2146-12-22] Discharge Date: [2146-12-28] Service: NEUROLOGY Allergies: Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: ICH s/p fall Major Surgical Invasive Procedure: none History Present Illness: Ms. [Known lastname 89562] 89 year-old right-handed woman history hypertension initially evaluated BIDN following fall transferred [Hospital1 18] found right thalamic hemorrhage intraventricular extension. . patient high-functioning baseline. lives independently. According patient's daughter, Ms. [Known lastname 89562] usual state health least day prior presentation. morning, answer patient's door meal service came deliver food. Emergency services contact[Name (NI) ]. patient reportedly found floor bathroom. patient's daughter shares prior transfer BIDN, patient "groggy" could identify family members. was, however, disoriented (eg thought living room actually bathroom) speaking "rag-time." . transferred BIDN evaluation. given morphine head, left shoulder, left hip pain fall. Imaging left hip, shoulder, c-spine, facial bones head performed. transferred [Hospital1 18] non-contrast CT head discovered show right thalamic hemorrhage. Past Medical History: - hypertension - hypothyroidism - macular degeneration - bilateral cataracts s/p repair Social History: - lives independently - 2 living children - previously worked high school cafeteria - avid reader prior [First Name8 (NamePattern2) ] [Last Name (un) ] Family History: - negative stroke, sz, migraine Physical Exam: NEUROLOGIC EXAMINATION: Mental Status: * Degree Alertness: Sleeping, arouses loud voice tactile stim. States hospital "boo boo ear." * Orientation: Oriented person, birthay (except year), indicates current year 1829 * Attention: inttentive. Able name days week forwards x 3 days * Memory: able correctly identify day, month birthdate. * Language: Language fluent semantic paraphasic errors neologisms. Often makes statements grammatically correct completely unrelated context (eg "what get brithday?") Repetition intact. Comprehension appears intact; pt able correctly follow midline appendicular commands. Prosody normal. Pt unable name high (pen= "pediwinkle", knuckles = "cars") low frequency objects (knuckles) without difficulty. * Calculation: Pt able calculate number quarters $1.50 Cranial Nerves: * I: Olfaction evaluated. * II: Pupils surgical, left slightly reactive right. * III, IV, VI: EOMI horizontal plane * VII: Face grossly symmetric * VIII: Hearing intact voice * IX, X: Palate difficult visualuze * XII: Tongue protrudes midline. Strength: * Left Upper Extremity: less voluntary movement tnan right, able grip * Right Upper Extremity: lifts least versus gravity, offers resistance push, pull, grip strong * Left Lower Extremity: moves least plane bed (difficult evaluate) * Right Lower Extremity: able lift versus gravity Sensation: * Intact tickle extremities Neuro exam discharge/ changes admit: Alert. Oriented self sometimes hospital. Able move right side gravity able hold >5 seconds. left bicep [1-21]. Delt /5 IP /5 Pertinent Results: [2146-12-22] 08:40PM GLUCOSE-171* UREA N-24* CREAT-1.1 SODIUM-140 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [2146-12-22] 08:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-2.1 [2146-12-22] 08:40PM WBC-15.8* RBC-4.57 HGB-13.7 HCT-39.7 MCV-87 MCH-30.0 MCHC-34.5 RDW-13.4 [2146-12-22] 08:40PM PLT COUNT-325 [2146-12-22] 08:40PM PT-12.2 PTT-23.1 INR(PT)-1.0 CT head [2146-12-25] IMPRESSION: change right thalamic hemorrhage extending ventricles, significant change ventricular size shape suggest developing hydrocephalus. new hemorrhage. CXR [2146-12-24] Lungs clear. Heart size normal. pulmonary edema, pleural effusion pneumothorax b/l Hip XR IMPRESSION: Degenerative changes throughout imaged field view detailed above. definite traumatic injury pelvis bilateral hips identified. Left Wrist XR IMPRESSION: 1. definite fractures. 2. Degenerative changes thumb CMC STT joints, described above. 3. Chondrocalcinosis suggesting CPPD. Brief Hospital Course: [Known lastname 89562] admitted found AMS. Initial evaluation [Hospital1 ] [Location (un) 620] revealed right thalamic bleed transfer [Hospital1 18] ICU done. reevaluated clnically CT scan head neck. bleed stable examination stable transferred floor care. wards stable occasional events A-fib RVR 140's responsive IV Beta Blocker. complications started heparin SC. inital event thought secondary hypertension. blood pressure within goal needed titration IPH: Secondary HTN. Stable IVH extension A-fib occasional RVR 140's: responsive metop 5mg IV. occured every day. HTN: Goal less 160 sytolic: Changed amlodipine 7.5 mg daily [2146-12-28] Speech swallow: able tolerate soft foods thin liquids. ID: developed fever [2146-12-28]. Urine [2146-12-24] grew Klebsiella P. Sensitive Ceftriaxone. started [2146-12-28]. Medications Admission: - toprol XL 200 mg po daily - norvasc 10 mg po daily - synthroid 88 mcg po daily - simvastatin 30 mg po daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain, fever. 7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) needed pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 9. Metoprolol Tartrate 5 mg IV Q4H:PRN SBP > 160 Hold HR < 55 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush 3 mL Normal Saline every 8 hours PRN. 11. HydrALAzine 10 mg IV Q6H:PRN SBP > 160 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. amlodipine Oral 15. CeftriaXONE 1 gm IV Q24H Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: New - Right Thalamic IPH - acute delirium Old - Hypothyroid - HTN - Macular degeneration - b/l cateract Discharge Condition: Mental Status: Confused - always. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: admitted right sided thalamic bleed. multiple images brain completed revealed stable bleed. surgical intervention done. Atrial fibrillation controlled time required PRN medications help control. also found UTI started antibiotic this. Followup Instructions: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]- Neurology Location: [Hospital Ward Name 23] Center Floor 8. Time/Date: [2-27] 3:30 Please call ensure date/time one week prior. ([Telephone/Fax (1) 7394] Completed by:[2146-12-28]	[ "5990", "4019", "2449" ]
Admission Date: [2160-12-7] [Month/Day/Year ] Date: [2160-12-22] Date Birth: [2114-3-20] Sex: F Service: MEDICINE Allergies: Methotrexate Attending:[First Name3 (LF) 3256] Chief Complaint: Altered mental status Major Surgical Invasive Procedure: [2160-12-7] endotracheal intubation [2160-12-7] femoral central venous catheter placement History Present Illness: 46F xfer OSH ([Hospital3 ]) found VNA earlier today. Recent hosp admission UTI, Klebsiella PNA completed antibiotics discharged home. History unclear, however [Location (un) ] reports liver transplant list. History rheumatoid arthritis ankylosing spondylitis Florinef. Outside hospital, patient intubated unresponsiveness. Received vancomycin Zosyn. Also noted left hip dislocation reduced ER. Hypotensive, requiring norepinephrine 2 L IV fluids. Transferred care. PH 7.1, CO2 50 bicarbonate 18 initial ABG. outside hospital, attempted right left IJ resulted subcutaneous fluid extravasation. . ED, initial vitals recieved hydrocortisone 100 mg IV chronically florinef right femoral CVL placed. Also, underwent CT head negative acute bleed CT torso showed bilateral aspiration versus effusions. hip reduced twice, vecuronium. . arrival MICU, intubated sedated initial vital signs 88/69, 120, 14, 100% AC (volume). . Review systems obtained patient intubated. Past Medical History: h/o Tylenol OD [10/2159] [5-/2160] c/b hepatic failure VAP foot necrosis [2-6] pressors Bilateral DVT [1-/2160] 8mm clean ulcer prepyloric antrum seen EGD [2160-4-15] (H.Pylori neg) c/b GIB bleed s/p transfusion 4U pRBCs Psychiatric disorder (anxiety vs bipolar) chronic pain h/o domestic abuse Crohn's disease anklyosing spondylitis Long term alcoholism h/o Hep iron-deficiency anemia Distal ileum resection [2-/2160] CCY [2156] R hip replacement [2153] c/b osteomyelitis L hip replacement [2156] also c/b osteomyelitis back/knee surgeries per past notes Social History: Lives apt [Location ] herself. currently relationship per case worker, though h/o domestic violence living domestic violence shelter last year. divorced positive relationship ex-husband. Daughter 25 y/o son 23 y/o. HCP [Name (NI) 553] [Name (NI) 1968] (HCP) - ([Telephone/Fax (1) 80620] Family History: Father - colitis? (frequent stomach pain) Mother - RA, ankylosing spondylitis Grandmother - ankylosing spondylitis Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.0, BP: 113/67, P: 119, R: 18 O2: 100% 100% FiO2 General: intubated, sedated HEENT: Sclera anicteric, MMM, pupils fixed non-reactive Neck: subcutaneous infiltration saline, unable assess LAD JVP CV: tachycardic, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, organomegaly GU: foley draining yellow urine Ext: cold, thready pulses, clubbing, cyanosis edema. left lower extremity chronic ulceration [Telephone/Fax (1) 894] PHYSICAL EXAM: Vitals: 97.8 150/82 72 18 99%RA General: WDWN female, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: lymphadenopathy, JVD CV: RRR, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, organomegaly, right hip small subcentimeter wound minimal serous drainage Ext: clubbing, cyanosis edema. left lower extremity chronic ulceration. left hand erythema edema previous PIV, pink granulation tissue (much improved since admission), left hip without swelling erythema, tender palpation pt able ambulate Skin: several macules right leg lower back central clearing c/w tinea corporis Neuro: & x 3, moving extremities Pertinent Results: ADMISSION LABS: [2160-12-6] 11:20PM BLOOD WBC-17.4* RBC-4.27 Hgb-11.5* Hct-38.5 MCV-90 MCH-27.0 MCHC-29.9* RDW-15.0 Plt Ct-248 [2160-12-6] 11:20PM BLOOD Neuts-95.2* Lymphs-3.3* Monos-1.4* Eos-0 Baso-0 [2160-12-6] 11:20PM BLOOD PT-11.8 PTT-36.0 INR(PT)-1.1 [2160-12-6] 11:20PM BLOOD Glucose-65* UreaN-66* Creat-2.2* Na-141 K-4.2 Cl-107 HCO3-14* AnGap-24* [2160-12-6] 11:20PM BLOOD ALT-156* AST-430* CK(CPK)-[Numeric Identifier 34197]* AlkPhos-132* TotBili-0.3 [2160-12-6] 11:20PM BLOOD Lipase-10 [2160-12-6] 11:20PM BLOOD cTropnT-<0.01 [2160-12-6] 11:20PM BLOOD Calcium-6.7* Phos-7.4* Mg-2.4 [2160-12-6] 11:20PM BLOOD Osmolal-314* [2160-12-6] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-POS [2160-12-7] 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17 Intubat-INTUBATED Vent-CONTROLLED [2160-12-6] 11:21PM BLOOD Lactate-0.6 [2160-12-7] 04:15PM BLOOD freeCa-1.02* . ABG TREND: [2160-12-7] 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17 Intubat-INTUBATED Vent-CONTROLLED [2160-12-7] 07:12AM BLOOD Type-[Last Name (un) ] Temp-38.0 Rates-22/0 Tidal V-450 PEEP-5 FiO2-60 pO2-62* pCO2-42 pH-7.21* calTCO2-18* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED [2160-12-7] 09:44AM BLOOD Type-ART Temp-38.2 Rates-22/ Tidal V-450 PEEP-10 FiO2-50 pO2-31* pCO2-51* pH-7.20* calTCO2-21 Base XS--9 -ASSIST/CON Intubat-INTUBATED [2160-12-7] 12:21PM BLOOD Type-CENTRAL Temp-37.2 pO2-170* pCO2-35 pH-7.35 calTCO2-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [2160-12-8] 09:44AM BLOOD Type-ART Temp-36.9 Tidal V-500 PEEP-8 FiO2-40 pO2-146* pCO2-40 pH-7.36 calTCO2-24 Base XS--2 Intubat-INTUBATED . [Month/Day/Year 894] LABS: [2160-12-21] 12:00PM BLOOD WBC-4.8 RBC-3.30* Hgb-9.0* Hct-28.7* MCV-87 MCH-27.3 MCHC-31.4 RDW-16.8* Plt Ct-448* [2160-12-21] 12:00PM BLOOD PT-21.7* INR(PT)-2.1* [2160-12-21] 12:00PM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-140 K-4.1 Cl-111* HCO3-23 AnGap-10 [2160-12-16] 03:42AM BLOOD ALT-38 AST-23 [2160-12-21] 12:00PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5* . URINE: [2160-12-6] 11:25PM URINE Color-LtAmb Appear-Hazy Sp [Last Name (un) ]-1.012 [2160-12-6] 11:25PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2160-12-6] 11:25PM URINE RBC-5* WBC-30* Bacteri-FEW Yeast-NONE Epi-2 [2160-12-6] 11:25PM URINE UCG-NEGATIVE [2160-12-6] 11:25PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG . MICRO: [12-6], 4, 6, 7 BLOOD CULTURES NGTD [2160-12-7] 11:00 SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [2160-12-7]): >25 PMNs <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS, CHAINS, CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. HEAVY GROWTH. BETA STREPTOCOCCI, GROUP A. MODERATE GROWTH. Blood Culture, Routine (Final [2160-12-16]): GROWTH. Blood Culture, Routine (Final [2160-12-16]): GROWTH. URINE CULTURE (Final [2160-12-11]): YEAST. >100,000 ORGANISMS/ML.. Stool Studies: FECAL CULTURE (Final [2160-12-13]): SALMONELLA SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2160-12-13]): CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2160-12-12]): OVA PARASITES SEEN. FECAL CULTURE - R/O VIBRIO (Final [2160-12-13]): VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [2160-12-13]): YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2160-12-12]): E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN & B TEST (Final [2160-12-12]): Feces negative C.difficile toxin & B EIA. CLOSTRIDIUM DIFFICILE TOXIN & B TEST (Final [2160-12-17]): Feces negative C.difficile toxin & B EIA. [2160-12-17]: C. difficile Toxin PCR Negative . IMAGING: [12-7] CT C/A/P: TECHNIQUE: MDCT axial images obtained chest, abdomen pelvis administration IV contrast. Multiplanar reformats generated reviewed. CT CHEST: Right pleural effusion adjacent compressive atelectasis. Left base opacification likely represents collapsed left lower lobe appears airless filled higher density material, possibly blood. patient nasogastric tube passes stomach. ETT tube appears approximately 4.7cm carina. visualized heart pericardium unremarkable. CT ABDOMEN PELVIS: intra-[Month/Day (4) 1676] vasculature intra-[Month/Day (4) 1676] solid organs incompletely evaluated absence IV contrast. Within limitation, liver, pancreas, bilateral adrenal glands appear unremarkable. Note made splenomegaly. kidneys show evidence large masses. non-obstructive 9-mm stone noted within lower pole left kidney (601B, 32). Small stones noted within right kidney. patient status post cholecystectomy. Surgical sutures noted RLQ, otherwise, intra-[Month/Day (4) 1676] loops large small bowel appear unremarkable. free air free fluid within abdomen. Retroperitoneal mesenteric lymph nodes meet size criteria pathologic enlargement. structures within pelvis incompletely evaluated due presence streak artifact due bilateral total hip replacements. Within limitation, patient status post Foley catheter. right femoral vein catheter identified. possible rectal catheter noted. Bilateral hip prosthesis noted; right femoral component appears well seated within acetabular component; however, left femoral component well seated within left acetabular component. Decrease vertebral body height L1 vertebral body noted possible retropulsion fragment spinal canal indentation thecal sac. indeterminate chronicity, likely represents chronic process presence looks like kyphoplasty material within L1 vertebral body. Intra-[Month/Day (4) 1676] vasculature well evaluated absence contrast technique. IMPRESSION: 1. Right pleural effusion adjacent compressive atelectasis. Left base opacification likely represents collapsed left lower lobe appears airless filled higher density material, possibly blood. 2. Left lower pole renal calculus. 3. Incomplete evaluation pelvis due streak artifact. 4. Left total hip arthroplasty prosthesis shows femoral component well seated within acetabular component. 5. Loss vertebral body height L1 vertebral body possible retropulsion fragments spinal canal; indeterminate chronicity, however, appears chronic due presence appears kyphoplastic material. . [12-7] CT HEAD:TECHNIQUE: Contiguous axial images obtained head without administration IV contrast. Multiplanar reformats generated reviewed. evidence acute fracture traumatic dislocation. Bilateral mastoid air cells clear. Minimal mucosal thickening noted within bilateral maxillary sinuses. evidence acute intracranial hemorrhage, discrete masses, mass effect shift normally midline structures. ventricles sulci normal size configuration. [Doctor Last Name ]-white matter differentiation preserved evidence large acute major vascular territory infarction. IMPRESSION: acute intracranial pathological process. ADDENDUM ATTENDING REVIEW: marked anterior rotation odontoid process relative thickened appearance body C2. finding likely represents fracture/subluxation deformity. resultant prominent central canal narrowing level. prevertebral soft tissue swelling locale. possible finding represents prior, healed fracture, clearly question must resolved, either obtaining prior records/imaging studies immediately, and/or subsequent spinal CT imaging. meantime, patient's neck needs stabilized. . [12-8] CT CSPINE: COMPARISON: CT head [2160-12-7] portable C-spine radiograph [2160-12-7]. TECHNIQUE: Helical 2.5-mm axial MDCT sections obtained skull base level T2. Sagittal coronal reformations obtained reviewed. FINDINGS: large mass new bone formation causing fusion C1 C2 vertebral bodies anteriorly, anterior subluxation C1 respect C2(400b:27). results severe encroachment spinal canal posterior arch C1. degree subluxation unchanged prior study. fracture identified. extensive fusion every facet joint C2 T3, comprising levels imaged. also interbody fusion involving every cervical level. surgical anterior fusion C6-7. extensive fusion lamina interlaminar ligaments throughout visualized levels. portion thoracic spine included study, fusion costovertebral costotransverse articulations. Comparison torso CT [2160-12-8] reveals similar ankylosis lumbar spine sacroiliac joints. findings indicate spondyloarthropathy manifestations typical ankylosing spondylitis. Correlation remainder medical history helpful. IMPRESSION: 1. Anterior subluxation C1 C2 without evidence fracture. anterior arch C1 fused odontoid process via thick layer bone contributes subluxation. produces severe encroachment spinal canal posterior arch C1. 2. extensive fusions multiple spinal joints suggestive ankylosing spondylitis. 3. evidence acute fracture. . [12-7] PELVIS PLAIN FILM: Comparison made selected images [Month/Day (4) 1676] pelvic CT scan dated [2160-12-7]. SINGLE PORTABLE AP PELVIC FILM OBTAINED [2160-12-7] 0452: Bilateral total hip replacements seen. femoral acetabular components appear well approximated single AP view. distal end femoral components included image. evidence loosening femoral components. Hypertrophic bone seen lateral right femoral component. right femoral catheter place. displaced fracture pelvis appreciated. Surgical chain sutures seen right lower quadrant, suggesting prior colonic surgery. Foley catheter place. Several radiopaque densities seen lateral left femoral component within soft tissues may sutural etiology. Clinical correlation advised. IMPRESSION: Bilateral total hip replacements appearing normally positioned single portable view. evidence displaced fracture pelvis. Left upper extremity ultrasound [2160-12-11]: IMPRESSION: Non-occlusive thrombus within one two paired brachial veins, extends axillary vein. Portable chest x-ray [2160-12-11]: IMPRESSION: Persistent sizable parenchymal infiltrate left lower lobe area. new abnormalities portable chest examination. Brief Hospital Course: Ms. [Known lastname 40984] 46 year old female history suicide attempts subsequent liver disease, multiple infections including ESBL Klebsiella osteomyelitis takes chronic steroids ankylosis spondylitis presented outside hospital intubated requiring pressors. . ACTIVE PROBLEMS ISSUE: # Acute metabolic acidosis without respiratory compensation: pH upon admission ICU 7.1 bicarb 14, later worsened 7.09 bicarb 12. possible etiologies primary metabolic acidosis include intoxication versus sepsis. active [Doctor Last Name 360]/s seem suppressed respiratory drive (additional respiratory acidosis) well causing primary metabolic acidosis. treated IV fluids bicarbonate well hyperventilation mechanical ventilation order improve acidosis elevated pCO2. Also, toxicology psychiatry services consulted assist identifying cause ingestion. Finally, started empirically piperacillin/tazobactam vancomycin cover possible aspiration pneumonia. . # Respiratory failure: intubated upon arrival able ventilated well including recruitment procedure open atelectatic lung seen CT. extubated easily well room air afterwards. discussed above, thought aspirated impaired unknown ingestion. CT chest consistent small bilateral pneumonia. Following stabilization extubation, induced sputum results returned positive MRSA. completed 7 day course vancomycin. remained afebrile throughout remainder course medical floor. PICC discontinued prior [Doctor Last Name ]. . # Hypotension: Pt hypotensive admission ICU. hypotension unclear etiology. seems possible sepsis--likely pneumonia. Also, may long enough miss home florinef dose, resulting hypotension. Lastly, ingestion could caused hypotension. treated IV fluids, antibiotics above, stress doses steroids. Blood pressures stable floor course. started captopril became hypertensive subsequent good control. . # Psychologic issues: suspect purposeful ingestion suicidal attempt. Blood tox positive benzos tricyclics. Urine tox positive benzos, cocaine, opiates. However, patient admit suicide ideation; intermittently reported may accidentally ingested medications intended. Psychiatry consulted recommended 1:1 sitter. placed section 12. followed psychiatry often refused full interviewing. admit suicide ideation given prior suicide attempts depression inability care herself, transferred psych facility care. psychiatric medications held hospital stay. started low dose seroquel floor prior transfer help sleep. . # Rhabdomyolysis: admission Creatinine 2.2 (baseline < 1.0) phosphate >7 CK [Numeric Identifier 24587]. treated IV fluids alkalinization urine (with bicarb). creatinine improved baseline CK trended quickly. . # Transaminitis: history liver disease secondary toxic ingestions. AST/ALT ratio suggests EtOH damage. APAP < 2 OSH. LFTs normalized time [Numeric Identifier ]. . # Odontoid fracture Hip dislocation: Patient originally arrived ED dislocated hip reduced. However, intubated awoke dislocated hip agitated. put brace second reduction. CT head showed old odontoid fracture, confirmed CT neck. kept immobilized cleared ortho spine team. hip, ortho recommended continue posterior hip precautions. weight bearing tolerated. . # Left upper extremity DVT: Patient failed bilateral internal jugular central lines outside hospital failed left subclavian left IR-guided PICC here. Imaging looks like type central obstruction, L brachiocephalic vein flow past venogram. eventually able get midline level axillary. Ultrasound showed left upper extremity DVT. initially started heparin gtt coumadin. transitioned lovenox coumadin. INR therapeutic several days 2 3 time [Numeric Identifier ] 3mg warfarin daily. Pt currently risk falling (due ankylosing spondylitis hip dislocations) syncope substance abuse. However, given transferred extended care facility, felt benefits anticoagulation would outweigh risks time. ready [Numeric Identifier ], another discussion anticoagulation. rehabilitation physical mental viewpoint, risks/benefits anticoagulation re-assessed. meantime, fall precautions continued psych facility . # Diarrhea: Pt several loose BMs daily. C.diff negative x 2. Given amount diarrhea, empirically started oral flagyl 500mg TID. C.diff PCR sent meantime. PCR returned negative flagyl discontinued. started immodium symptomatic relief . # Tinea corporis: Pt several macular patches lower back right leg central clearing. consistent tinea corporis. treated clotrimazole cream [Hospital1 ]. . # Pain control: Pt longstanding history narcotic use. frequently demanded IV dilaudid nonspecific complaints, including [Hospital1 1676] pain. Also ankylosing spondylitis, left hip dislocation, left hand IV infiltration levophed OSH contribute pain. Pain consult obtained recommended maintaining current narcotic regimen oral dilaudid q6h. also given lidoderm patch ibuprofen pain relief. Oral dilaudid transitioned oral oxycodone prior [Hospital1 ] patient reported satisfactory. . # Communication: [Name (NI) 553] [Name (NI) 1968] (HCP) - ([Telephone/Fax (1) 80620]; [First Name5 (NamePattern1) ] [Name (NI) 80606] (son) - [Telephone/Fax (1) 80609] Medications Admission: clonazepam 1 mg [Hospital1 ], 0.5 mg daily tizanidine 2 mg qhs ranitidine 150 mg [Hospital1 ] trazodone 50 mg daily gabapentin 800 mg tid fentanyl patch 50 mcg/hr every 72 hours ketoconazole tramadol 50 mg qid macrobid 100 mg [Hospital1 ] [Hospital1 ] Medications: 1. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times day). 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours daily. 3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times day): Use twice daily [2160-12-31]. 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) needed pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) needed nausea. 7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 10. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times day) needed diarrhea. [Month/Day/Year ] Disposition: Extended Care Facility: [Hospital1 ] 4 [Hospital1 ] Diagnosis: Overdose Depression/ Hx suicide attempt Pneumonia Left upper extremity DVT Hypertension Tinea corporis [Hospital1 ] Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). [Hospital1 ] Instructions: pleasure taking care hospital. admitted found home unconscious. intubated ICU. likely ingestion caused lose consciousness. transferred psychiatric facility continue receive mental health care. hospital stay, treated pneumonia IV antibiotic; finished course. also started blood thinner called coumadin blood clot found left arm. need levels medication blood monitored 2-3 times weekly. psychiatric physical rehabilitation, risks benefits blood thinners revisited determine long stay medication. Please see attached sheet new medications. Followup Instructions: seen psychiatrists physicians facility. Completed by:[2160-12-22]	[ "5849" ]

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